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 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

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.