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The Clinical Management of Obesity in Primary Care Dr. Sean Wharton, MD, FRCPC, PharmD Internal Medicine Wharton Medical Clinic Adjunct Professor – York.

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Presentation on theme: "The Clinical Management of Obesity in Primary Care Dr. Sean Wharton, MD, FRCPC, PharmD Internal Medicine Wharton Medical Clinic Adjunct Professor – York."— Presentation transcript:

1 The Clinical Management of Obesity in Primary Care Dr. Sean Wharton, MD, FRCPC, PharmD Internal Medicine Wharton Medical Clinic Adjunct Professor – York University Lead Author – Weight Management in Diabetes CDA Guidelines 2013

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 Understand the degree of the epidemic of Obesity and the impact in Canada Understand current systems to deliver bariatric care in Canada.

4 Canadian Guidelines for Body Weight Classification in Adults ClassificationBMI (kg/m 2 )Risk of Health Problems Underweight<18.5Increased Normal weight18.5-24.9Least Overweight25.0-29.9Increased Obese≥30.0 Class I30.0-34.9High Class II35.0-39.9Very High Class III≥40.0Extremely High Health Canada. Canadian Guidelines for Body Weight Classification in Adults. 204 Ottawa, ON: Health Canada; 2003. Publication H49-179/2003E.

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8 Pulmonary disease abnormal function obstructive sleep apnea hypoventilation syndrome Nonalcoholic fatty liver disease steatosissteatohepatitiscirrhosis Coronary heart disease Diabetes Diabetes Dyslipidemia Dyslipidemia Hypertension Hypertension Gynecologic abnormalities abnormal menses infertility polycystic ovarian syndrome urinary incontinence Osteoarthritis Skin fungal/bacterial infections Gall bladder disease Cancer breast, uterus, cervix colon, esophagus, pancreas kidney, prostate Phlebitis/DVT (Blood Clots) venous stasis Gout Medical Complications of Increased Weight Stroke Cataracts Severe pancreatitis

9 Overweight - BMI 25 - 30 Greater in Men or Women? More overweight men 42% vs 30% women Android – Apple shape

10 Android – Apple Shape Metabolic Syndrome Metabolic Syndrome High Blood Pressure High Blood PressureHypertension High Cholesterol High Cholesterol High Blood Sugar High Blood SugarDiabetes

11 Visceral Fat vs Subcutaneous Fat A B Visceral Fat Subcutaneous Fat Courtesy: Steven Smith, MD Pennington Biomedical Research Center Cardiometabolic Risk

12 Kershaw EE, et al. J Clin Endocrinol Metab. 2004;89:2548-2556. Lee YH, et al. Curr Diab Rep. 2005;5:70-75. Boden G, et al. Eur J Clin Invest. 2002;32:14-23. Ahima RS. Trends Endocrinol Metab. 2005;16:307-313. Excess abdominal fat is typically accompanied by ↑CRP, ↑FFAs, and adiponectin Leptin TNF-α IL-6 Angiotensin Sex steroids Glucocorticoids Adiponectin PAI-1 TGF-β AdipoQ TF Adipsin/ASP TNF-α IL-6 Leptin Renin- angiotensin system Steroid hormones Endocrine PAI-1 Autocrine Paracrine Intra-abdominal Adiposity: Metabolically Active

13 Morbid Obesity - BMI > 40 Greater in Men or Women?? Morbid Obesity 4% women vs 1.5% men Gynaeoid Shape – Pear Less cardiometabolic conditions Mechanical comorbidities Arthritis, urinary incontinence, fatty liver

14 Gynaeoid Shape - Pear Shape Curved hips and thighs Small tapered waist Due to estrogen Low risk of metabolic disease Hard to lose fat from the buttocks and thighs

15 Edmonton Obesity Staging System (EOSS) Stage 0 Sharma AM & Kushner RF, Int J Obes 2009 Stage 1 Stage 2 Stage 3 Stage 4 Medical Mental Functional absent pre-clinical risk factors mild co-morbidity moderate end-organ damage severe end-stage Obesity

16 EOSS - Treatment Stage 0, Stage 1 Stage 0, Stage 1 Stop Further Weight Gain with lifestyle modifications Stop Further Weight Gain with lifestyle modifications Stage 2, 3 Stage 2, 3 Initiate Weight Loss Efforts and Weight Loss Maintenance Initiate Weight Loss Efforts and Weight Loss Maintenance Stage 4 Stage 4 Aggressive obesity management or palliative measures (pain management etc.) Aggressive obesity management or palliative measures (pain management etc.)

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18 EOSS Predicts Mortality in NHANES III Padwal R, Sharma AM et al. CMAJ 2011

19 EOSS Predicts Mortality at Every Level of BMI NHANES III Padwal R, Sharma AM et al. CMAJ 2011

20 EOSS Across BMI Categories NHANES III (1988-1994) Overweight 50 million 23 million 10 million Class III 6 million Padwal R, Sharma AM et al. CMAJ 2011

21 Obesity Treatment Pyramid Psychological

22 Phases of Obesity Treatment Phase I (Weight Loss) 3-6 months Phase II (Weight-Loss Maintenance) Indefinitely When you stop treatment, the disease comes back! Weight www.drsharma.ca

23 Energy Balance Energy Expenditure Energy Intake What are the driving forces for this system??

24 Energy Balance Energy Expenditure Energy Intake What are the driving forces for this system?? Metabolic Rate Voluntary Movement (Exercise)

25 An Aetiological Framework for Obesity Metabolism Diet Activity OUTIN SKELETAL MUSCLE Sharma A, Padwal R. Obesity Reviews, 2009

26 Muscle vs Fat 1 lb of muscle burns 6 calories a day 1 lb of fat burns 2 calories a day Heymsfield SB, Gallagher D, Wang Z. Ann N Y Acad Sci. 2000 May;904:290-7.

27 Energy to Muscle instead of Fat 6 Calories 1 muscle fibre Resistance Exercise Protein 3 Fat Cells Inactivity Carbohydrates

28 An Aetiological Framework for Obesity Diet Activity OUTIN AGE SKELETAL MUSCLE Sharma A, Padwal R. Obesity Reviews, 2009 Metabolism

29 Age and Metabolism Lose 2 % of BMR each decade after age 20 Lose 2 % of BMR each decade after age 20 20 yo, woman, 5’5”, 250lbs BMR = 1954 60 yo, woman, 5’5”, 250lbs BMR = 1766 (8% less) N. K. Fukagawa, L. G. Bandini and J. B. Young, Am J Physiol Endocrinol Metab 259 Can gain 10 – 20lbs/year

30 An Aetiological Framework for Obesity Diet Activity OUTIN AGE GENDER SKELETAL MUSCLE Sharma A, Padwal R. Obesity Reviews, 2009 Metabolism

31 Gender and Metabolism Men – 15% higher metabolism than women Men – 15% higher metabolism than women 50 yo, man, 5’7”, 250lbs BMR = 2134 50 yo, woman, 5’7”, 250lbs BMR = 1822 (15% less ) C Compher, et al. Journ Amer Dietetic Assoc. V.106,;6 881-903, 2006.

32 An Aetiological Framework for Obesity Metabolism Diet Activity OUTIN AGE GENDER GENETICS SKELETAL MUSCLE HORMONES Sharma A, Padwal R. Obesity Reviews, 2009

33 Leptin (trying to keep you thin) Leptin Stop eating Increase metabolism MD Klok, S Jakobsdottir, ML Drent - Obesity reviews, 2007

34 Rehfeld J, 2004 1967 – Gastric Bypass DISCOVERY OF GASTROINTESTINAL HORMONES

35 An Aetiological Framework for Obesity Diet Activity OUTIN AGE GENDER GENETICS HORMONES SKELETAL MUSCLE MEDICATIONS SKELETAL MUSCLE Sharma A, Padwal R. Obesity Reviews, 2009 Metabolism

36 SSRI=Selective Serotonin Reuptake Inhibitor. Selected Medications That Can Cause Weight Gain Psychotropic medications Psychotropic medications Tricyclic antidepressants Tricyclic antidepressants Monoamine oxidase inhibitors Monoamine oxidase inhibitors Specific SSRIs Specific SSRIs Atypical antipsychotics Atypical antipsychotics Lithium Lithium Specific anticonvulsants Specific anticonvulsants  -adrenergic receptor blockers  -adrenergic receptor blockers Diabetes medications Diabetes medications Insulin Insulin Sulfonylureas Sulfonylureas Thiazolidinediones Thiazolidinediones Highly active antiretroviral therapy Highly active antiretroviral therapy Tamoxifen Tamoxifen Steroid Hormones Steroid Hormones Glucocorticoids Glucocorticoids Progestational steriods Progestational steriods 36/26

37 Weight GainWeight Effect (kg) Insulin+4.5 to 5.0 Thiazolidenediones (TZDs)+4.2 to 4.8 Sulfonylureas+1.6 to 2.6 Meglitinides+ 0.7 to 1.8 Weight Neutral or Decrease WeightWeight Effect (kg) Metformin-4.6 to 0.4 α-Glucosidase inhibitors+0.0 to 0.2 Dipeptidyl peptidase-4 (DPP-4) inhibitors+0.0 to 0.4 Glucagon-like peptide-1 (GLP-1) receptor agonists -1.3 to 3.0 Consider Weight Effects When Selecting Antihyperglycemic Medications Hollander, P. Diabetes Spectrum 2007; 20(3): 159-165

38 An Aetiological Framework for Obesity Diet Activity OUTIN AGE GENDER GENETICS HORMONES SKELETAL MUSCLE MEDICATIONS WEIGHT LOSS SKELETAL MUSCLE Sharma A, Padwal R. Obesity Reviews, 2009 Metabolism

39 Weight loss decreases metabolism 3% decrease for each 10lbs lost 3% decrease for each 10lbs lost 50 yo, woman, 5’7”, 250lbs BMR = 1822 50 yo, woman, 5’7”, 175lbs BMR = 1496 (18% less ) R Leibel, M Rosenbaum, J Hirsch. Changes in Energy Expenditure Resulting from Altered Body Weight. NEJM Vol 332:621-628, 1995

40 Long-term weight-loss maintenance: Meta-analysis 13 Studies 1,081pts 6 months 14% Weight Anderson et al. Am J Clin Nutr, 2001 5% Weight Loss 40.5% of pts 10% Weight Loss 25% of pts 4.5 years 3% Weight Loss average

41 Obesity Treatment Pyramid Psychological

42 Bariatric Surgery Criteria OBN (Ontario Bariatric Registry) OBN (Ontario Bariatric Registry) http://www.bariatricregistry.ca/ http://www.bariatricregistry.ca/ http://www.bariatricregistry.ca/ Criteria Criteria BMI > 40 BMI > 40 BMI 35 – 40 BMI 35 – 40 2 of the following: Diabetes, OSA, Heart Disease, Hypertension not controlled on 2 medications 2 of the following: Diabetes, OSA, Heart Disease, Hypertension not controlled on 2 medications

43 Bariatric Surgery Effect on Cardiovascular Risk A Systematic Review and Meta-Analysis of 22,090 Patients % resolved 62% 70% 77% 86% Hypertension Dyslipidemia Diabetes Sleepapnea Buchwald H, et al. JAMA 2004;292:1724

44 Canadian Institute of Health Information 2014

45 Roux-en-Y Gastric Bypass Restrictive and Malabsorptive Restrictive and Malabsorptive Laparoscopic Laparoscopic 30-35% Weight 30-35% Weight 10 – 20% regain 10 – 20% regain Mortality 1/500 (0.2%) Mortality 1/500 (0.2%) Morbidity 20-26/200 Morbidity 20-26/200 Covered by OHIP Covered by OHIP $20,000 $20,000

46 Sleeve Gastrectomy Restrictive Restrictive Laparoscopic Laparoscopic 30-35% Weight 30-35% Weight 10 – 20% regain 10 – 20% regain Mortality 1/500 (0.2%) Mortality 1/500 (0.2%) Morbidity 20-26/200 Morbidity 20-26/200 Covered by OHIP Covered by OHIP $20,000 $20,000

47 Ring creates small pouch Ring creates small pouch 15 – 25% Weight Loss 15 – 25% Weight Loss Frequent follow-up needed Frequent follow-up needed Mortality - 1/10,000 Mortality - 1/10,000 Morbidity – 5% Morbidity – 5% Slippage Slippage Erosion Erosion Not covered by OHIP Not covered by OHIP $16 - $18,000 $16 - $18,000 Laparoscopic Gastric Banding

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50 1995-“Who Would Have Thought It? Pories et al. Annals of Surgery NIDDM is no longer an uncontrollable disease NIDDM is no longer an uncontrollable disease The correction on NIDDM occurs within days following gastric bypass, long before significant weight loss has occurred The correction on NIDDM occurs within days following gastric bypass, long before significant weight loss has occurred Decrease caloric intake and changes in incretin stimulation of the islets by the gut may play a role Decrease caloric intake and changes in incretin stimulation of the islets by the gut may play a role

51 Surgery is doing more than restriction Shin et al. Int J Obes (Lond). May 2011; 35(5): 642–651.

52 WMC – BMI > 40 - Are you interested in Surgery? (842pts) YES – SURGERY NO – NOT INTERESTED THINKING ABOUT IT NOT ELIGIBLE

53 WMC – BMI > 40 (Surgery?) N = 842 (June 2013) 70% 20% 6% 4% YES – SURGERY CONSIDERING NOT ELIGIBLE NO – NOT INTERESTED

54 Treatment Success Change in Weight Years Lifestyle (LS) ~3-5% Source: Sharma, A LS + Pharmacotherapy ~5-10% LS + Surgery ~20-30%

55 Medications Orlistat (Xenical) Orlistat (Xenical) Decreases fat absorption Decreases fat absorption Diarrhea Diarrhea Liver failure Liver failure Newer medications in the US Newer medications in the US Liraglutide 3.0mg approved by FDA, submitted to Health Canada Liraglutide 3.0mg approved by FDA, submitted to Health Canada

56 Diabetes Medications and Weight Loss GLP 1 analogues – Liraglutide, Exenatide GLP 1 analogues – Liraglutide, Exenatide A1c decrease of 1% A1c decrease of 1% Weight loss 5 – 10 lbs Weight loss 5 – 10 lbs SGLT2 inhibitors – Canagliflozin SGLT2 inhibitors – Canagliflozin A1c decrease 1% A1c decrease 1% Weight loss of 3 – 8 lbs Weight loss of 3 – 8 lbs

57 Who Got Bariatric Surgery in Canada? 2007 – 2009 – Survey (CHMS) Surgical candidates - 1.5 million 1,500 pts – 0.1% Padwal R et al. International journal for equity in health, 11 2012 (2013 stats) 5,300 pts – 0.35% (hypothetical) 10,600 pts – 0.70%

58 Canadians Requiring Bariatric Care 2007 – 2009 - Survey Overweight and Obese 15 million Overweight and Obese 15 million Obese 3.4 million Obese 3.4 million Morbidly obese 0.7 million Morbidly obese 0.7 million Surgical candidates1.5 million Surgical candidates1.5 million Padwal R et al. International journal for equity in health, 11 2012

59 Current Environment for Community Based Weight Management Commercial Commercial Weight Watchers Weight Watchers Bernstein’s Bernstein’s Herbal Magic Herbal Magic Evidence Based Practices Evidence Based Practices BMI (Bariatric Medical Institute) BMI (Bariatric Medical Institute) Wharton Medical Clinic Wharton Medical Clinic Medical Centres/Hospitals Medical Centres/Hospitals ?Family Medicine Clinics ? ?Family Medicine Clinics ? Yoni Freedhoff, MD

60 Principles for Obesity Treatment 2011 National Obesity Summit Workshop

61 Principles for Obesity Treatment 2011 National Obesity Summit Workshop

62 Diabetes Prevention Program: Incidence of Diabetes Cumulative Incidence of Diabetes (%) Year Placebo 00.51.01.52.02.53.03.54.0 Metformin Lifestyle 31% 58% Reprinted from Diabetes Prevention Program Research Group. N Engl J Med. 2002; 346: 393-403. Copyright © 2002 Massachusetts Medical Society. All rights reserved.

63 Diabetes Prevention Program: Weight Loss Reprinted from Diabetes Prevention Program Research Group. N Engl J Med. 2002; 346:393-403. Copyright © 2002 Massachusetts Medical Society. All rights reserved. Change in Weight (kg) Year Placebo 0.00.51.01.52.02.53.03.54.0 Metformin Lifestyle -8 -6 -4 -2 0 2 4

64 Barry at 404 lbs, BMI 60 Obesity Class III Diabetes Type 2 OSA – CPAP Hypertension High Cholesterol Developmental Delay MEDs Metformin, Glyburide Ramipril, Lipitor

65 Barry’s Weight Loss Graph

66 Barry at 231lbs, BMI 33 176lbs lost, 43% WL Current Medical Hx Obesity Class I OSA CPAP turned down Diabetes type 2 Diet controlled Current Medications No medications Off – metformin, ramipril, glyburide. Lipitor

67 Barry’s Weight Management Graph 2007 2014 Regain 110lbs 16% weight loss 2012 Loss 176 lbs 43% weight loss

68 Conclusion Obesity has become a pandemic Obesity has become a pandemic Overweight in men should not be overlooked Overweight in men should not be overlooked Metabolic rate – 80% of energy expenditure Metabolic rate – 80% of energy expenditure Leptin resistance can lead to obesity Leptin resistance can lead to obesity Lifestyle modification is challenging Lifestyle modification is challenging Bariatric Surgery – Gold Standard Bariatric Surgery – Gold Standard For BMI >40 For BMI >40 Medications can bridge the gap Medications can bridge the gap

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


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