AlZougbiAsma.2019 IPAS Evaluation and Mangement of …...9/23/19 1 Asma Al-Zougbi, MD, MME IPAS 2019...

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Asma Al-Zougbi, MD, MME

IPAS 2019

Evaluation and Management of Obesity

Disclosure

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• I have no financial disclosures for this presentation, however will be discussing off-label drug use.

Learning Objectives

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Upon successful completion of this activity, participants should be able to:1) Evaluate the complications of overweight and obesity. 2) Determine the causes of overweight and obesity. 3) Utilize specific interviewing methods to actively involve patients in setting treatment goals.4) Determine the most suitable pharmacotherapy for patients based on patient comorbidities and preferences; drug efficacy, mechanism of action and side effects. 5) Develop individualized treatment plans with his/her patients using the 4 pillars of weight management.

Prevalence of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2011

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Obesity on the Rise• 10% increase in the prevalence of obesity in the United

States since 2005–2006

• 600% increase in the prevalence of severe obesity since the mid-1980s.

Flegal et al, JAMA 2016; 315(21):2284-2291Sturm et al, Int J Obes 2013; 37(6):889-891 1 2

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Grading of BMI

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BMI Weight Status

Below 18.5 Underweight

18.5 – 24.9 Normal or Healthy Weight

25.0 – 29.9 Overweight

30.0 – 34.9 Class I Obesity

35.0 – 39.9 Class II Obesity

>40.0 Class III (Severe) Obesity

www.cdc.gov

4 Pillars of Obesity Management

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Obesity

Nutrition

Activity

Behavior

Meds

4 Pillars of Obesity Management

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Obesity

Nutrition

Activity

Behavior

BariatricSurgery

Bariatric Surgery

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Qualifications:• BMI ≥ 40, or more than 100 pounds overweight.• BMI ≥ 35 and at least one or more obesity-related co-

morbidities • Inability to achieve a healthy weight loss sustained for a

period of time with prior weight loss effortsResults in an average of 40-70% excess weight loss at 5 year follow up.Up to 89% reduction in mortality compared to obese people who have not had bariatric surgery.

Source: www.asbms.org

Learning Objectives

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Upon successful completion of this activity, participants should be able to:1) Evaluate the complications of overweight and obesity. 2) Determine the causes of overweight and obesity3) Utilize specific interviewing methods to actively involve patients in setting treatment goals.4) Determine the most suitable pharmacotherapy for patients based on patient comorbidities and preferences; drug efficacy, mechanism of action and side effects. 5) Develop individualized treatment plans with his/her patients using the 4 pillars of weight management.

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>200 Complications of Obesity

Yuen et al. Obesity Week: 2016.1 9 2 0Image Source: www.lbcoaching.co.za.

Complications of Obesity

2 1Image Source: mycme.com

• Type II diabetes • Hypertension• Sleep apnea and other respiratory disorders• Non-alcoholic fatty liver disease• Osteoarthritis• Lipid abnormalities• Gastrointestinal disorders• Heart disease

Effect of Weight Loss on Complications of Obesity

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Diabetes prevention in impaired glucose tolerance

2.5% weight loss or more; maximal impact at 10%

Type 2 diabetes 2.5% to >15%; greater weight loss associated with greater glycemic improvement; true for all BMI classes

Infertility in PCOS Improvement in ovulatory cycles and subsequent pregnancy with 2–5% weight loss, with more weight loss producing more robust effect.

Sexual Function 5–10% improves erectile function in men and sexual dysfunction in women

Apnea Hypopnea Index Improvement in Obstructive Sleep Apnea

>10% results in significant improvement

Major cardiovascular outcomes(MACE)

>10% with medical management; 16% with vertical band

Ryan and Yockey. Curr Obes Rep 2017; 6(2):187-194.

Learning Objectives

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Upon successful completion of this activity, participants should be able to:1) Evaluate the complications of overweight and obesity. 2) Determine the causes of overweight and obesity. 3) Utilize specific interviewing methods to actively involve patients in setting treatment goals.4) Determine the most suitable pharmacotherapy for patients based on patient comorbidities and preferences; drug efficacy, mechanism of action and side effects. 5) Develop individualized treatment plans with his/her patients using the 4 pillars of weight management.

Genetics (80%)

Mark. Hypertension 2008; 51: 1426-1434.Borjeson. Acta Paediatr Scand 1976; 65: 279-287.

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Genetics- Monogenic Obesity (Rare)• Leptin or leptin receptor mutation (3% of severe early

onset obesity)• Melanocortin-4 receptor mutation (5% of severe early

onset obesity)• Proopiomelanocortin mutation• Prader Willi Syndrome• Bardet-Biedl Syndrome

(early onset with severe hyperphagia due to decreased satiety)

2 5Mark. Hypertension 2008; 51: 1426-1434.

Genetics- Polygenic Obesity (majority)• Remains poorly understood

2 6Goodrazi. Lancet 2018; 6(3): 222-236.

Environment (everything else)

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EnvironmentGenes


2 8Mark. Hypertension 2008; 51: 1426-1434.

Why is it so hard to lose weight (and keep it off)?• Fat Set Point Theory and Metabolic Adaptation

2 9Fothergill. Obesity 2016: 24; 1612-1619.


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• Lifestyle• Medications• Occupation• Illness• Sleep• Etc.

Micro

• Public Health Initiatives• Cost of Food• Food Insecurity• Culture• Built environment• Technological advancement• Leisure activities• Etc.

Macro

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Modifiable Causes of Obesity

Obesity

InadequateSleep

(Quality)

Medications

Physical Activity

Irregular Eating

PatternsProcessed Diets

Medical Illness

Circadian Rhythm

Vulnerable periods

Image source: medium.com

Medication Induced Weight Gain

3 2Picture source: insights.som.yale.edu


3 3Saunders et al, J Fam Pract. 2016





Inadequate Sleep

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• Duration• Interruptions• Restfulness• Shift work• Regularity• Restless Leg Syndrome

Assess

• Regular Sleep Patterns• Control Environment• Consistent Shifts• Circadian Rhythm• Melatonin or Magnesium

Treat

Hargens et al. Nat Sci Sleep 2013; 5: 27-35.

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Inadequate Sleep- Obstructive Sleep ApneaEppworth Sleepiness Scale (ESS) or STOP-Bang questionnaire

Picture Source: Uptodate.com3 7

Medical Illness Induced Weight gain

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• Cushing’s syndrome– Purple striae, fat pads,

rapid weight gain, etc.• Hypothyroidism

– Check TSH• Hypothalamic Injury

– Usually apparent from history

Assess for

• Refer to endocrinologist• Treat hypothyroidism

Treat

Vulnerable Periods

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• Gestation• Young childhood• Puberty• Pregnancy• Menopause

Assess

• Close follow up, counseling, nutritionist or psychothrapist referral during vulnerable times

Treatment

Eating Patterns

• 24 Hour Food Recall (Typical vs the day before)– Or food diary or food

frequency questionnaire• Sugar Sweetened

Beverage consumption

Assess

• Nutritional counseling• Food Log • Control Environment

(Food, Cues, Rewards)• Replace-Remove-Limit

Treat

Irregular Eating Patterns

• Night Eating Syndrome– Wake up to eat or eat

large amounts after supper• Binge Eating Disorder

– Eat large amounts of food in discrete time period, with sense of lack of control

• Stress/Emotional Eating

Assess

• Control Environment (Food, Cues, Rewards)

• Food Log (with or without triggers)

• Psychotherapy or psychiatry referral

Treat

Physical Activity

• Total Weekly Duration• Type of Activity• Intensity• Job-related Activity

Assess

• Exercise and Diet• Weight Loss Maintenance

Treat

Catenacci and Wyatt. Nat Rev 2007;3:518-529.

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My Note Template

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• Obesity History• Weight in late teens: *** lb.• Period of greatest weight gain: *** lb during {age at

onset:1209}• Lowest adult weight: ***• Highest adult weight: ***• Amount of time at present weight: ***.

• History of Weight Loss Efforts• Greatest amount of weight lost: *** lb over *** months• Amount of time that loss was maintained: *** months• Circumstances associated with regain of weight: ***• Successful weight loss techniques attempted:

{obesity treatment:12513}• Unsuccessful weight loss techniques attempted:

{obesity treatment:12513}

• 24 Hour Food Recall• ***

• Current Eating Habits• Number of regular meals per day: {0-10:33138}• Number of snacking episodes per day: {0-10:33138}• Who shops for food? {companion:5061::"patient"}• Who prepares food? {companion:5061::"patient"}• Who eats with patient? {companion:5061::"patient"}• Binge behavior?: {yes***/no:17258}• Purge behavior? {yes***/no:17258}• Anorexic behavior? {yes***/no:17258}• Eating precipitated by stress? {yes***/no:17258}• Guilt feelings associated with eating?

{yes***/no:17258}

• Current Exercise Habits {exercise types:16438}

• Other Potential Contributing Factors• Use of alcohol: average *** drinks/week• Use of medications that may cause weight gain

{meds:16753}• History of past abuse? {abuse type:16542}• Psych History: {ros - neuro psych list:32387}• Comorbidities: {assd:16751}

My Note Template Cont’d

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Lab Results

Com ponent Value Date

TSH 0.35 06/14/2019

TSHR 0.86 07/13/2011

FT4 1.50 06/14/2019

EXTTSH 0.676 01/14/2016

EXTFT4 1.74 01/14/2016

HBA1C 6.7 (H) 06/14/2019

CHOL 160 06/14/2019

TRIG 113 06/14/2019

LDLC 94 06/14/2019

HDLP 43 06/14/2019

AST 25 09/20/2010

ALT 33 (H) 09/20/2010

Needed labs: TSH,FT4,HBA1C,BMP, Lipid panel, AST, AL

Previous labs:

Learning Objectives

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Upon successful completion of this activity, participants should be able to:1) Determine the causes of overweight and obesity. 2) Evaluate the complications of overweight and obesity. 3) Utilize specific interviewing methods to actively involve patients in setting treatment goals.4) Determine the most suitable pharmacotherapy for patients based on patient comorbidities and preferences; drug efficacy, mechanism of action and side effects. 5) Develop individualized treatment plans with his/her patients using the 4 pillars of weight management.

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Obesity

Inadequate Sleep

(Quality)

Meds

Physical Activity

Irregular Eating


Medical Illness

Circadian Rhythm

Vulnerable periods

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Obesity

Inadequate Sleep

(Quality)

Meds

Physical Activity

Irregular Eating


Medical Illness

Circadian Rhythm

Vulnerable periods

Behavioral TherapyAssumptions:1. Learned maladaptive patterns contribute to/maintain

obesity2. These behaviors can be modified to result in weight

loss

Goals:1. Alter the environment2. Alter environmental reinforcement3. Adjust eating behavior and physical activity

4 8Jacob and Isaac. Ind J Endocrinol Metab 2012; 16(1): 28-32.

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Behavioral TherapyCharacteristics1. Clear goal setting (SMART).2. Identify how to change habits rather than deciding what

to change.3. Focus on small changes rather than large changes.


Behavioral TherapyElements:1. Setting initial goals (patient’s, not yours)2. Self-monitoring (keeping food diaries and activity records)3. Stimulus Control (avoid activation of eating and overeating)4. Slower eating (no distractions)5. Behavioral contracting and reinforcement (feasible, measurable goals)6. Nutrition education and meal planning7. Increasing physical activity8. Social support9. Problem-solving


SMART Goals

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SMART Goals

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Take a few moments to think about a goal that you have, and write down a SMART goal

Image Source: www.psu.instructure.com

Chicken Divan StoryE-P-E• Elicit: Ask for permission to discuss X. Ask what

the patient knows about X. Ask for permission to tell them more about X.

– Do you mind if we discuss…– What’s your understanding about…

• Provide: Ask for permission to tell them more about X. Give information in a neutral, nonjudgemental fashion. Avoid “I” and “you.”

– If its alright, I’d like to share with you something else about X…

– Research shows that…

• Elicit: Ask about the patient’s understanding/ interpretation.

– What does this mean to you?– How does that change your thoughts about X?

Adapted from Motivational Interviewing for Brief Intervention Settings. (oregon.gov)

Learning Objectives

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Use of Weight Loss Medications

5 5Thomas et al. Obesity 2016; 24(9): 1955-1961.

2018 Endocrine Society Guidelines

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• BMI ≥ 25 kg/m2 : diet, exercise, and behavioral modification• BMI ≥ 27 kg/m2 with comorbidity or BMI over 30 kg/m2: +

pharmacotherapy• BMI ≥ 35 kg/m2 with comorbidity or BMI over 40 kg/m2: + bariatric

surgery

• “Drugs may amplify adherence to behavior change and may improve physical functioning such that increased physical activity is easier in those who cannot exercise initially. Patients who have a history of being unable to successfully lose and maintain weight and who meet label indications are candidates for weight loss medications.”

Apovian et al. JCEM 2015; 100 (2): 342-362.

Phentermine (Adipex, Lomaira)- controlled substance

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• MoA: norepinephrine releasing agent• Mean Loss: 3.6 kg • Contraindications Include: Anxiety, heart disease,

uncontrolled HTN or hyperthydoism, SZ, MAOi, history of drug abuse, sympathomimetic amines

• Common Side Effects: HA, elevated BP, dry mouth, insomnia, ischemic events, overstimulation

• Advantages: inexpensive• Disadvantages: side effect profile, no long term data• Similar for diethylpropion


Topiramate/Phentermine (Qsymia)

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• MoA: T GABA receptor modulator; noepinephrinereleasing agent

• Mean Loss: 6.6 kg to 8.6 kg over 1 year• CI include: hyperthyroidism, glaucoma, MAO inhibitor,

sympathomimetic amines• Common SE: Insomnia, dry mouth, constipation,

paraesthesia, dizziness, dysgeusia, (kidney stones)• Advantages: Robust weight loss, long term data• Disadvantages: expensive, teratogen


Lorcaserin (Belviq, Belviq XR)

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• MoA: 5HT2c receptor agonist• Mean Loss: 3.6 kg over 1 year• Use with caution: SSRI, SNRI/MAOI, St John's wort,

triptans, buproprion, dextromethorphan• Common SE: Headache, nausea, dry mouth, dizziness,

fatigue, constipation• Advantages: low SE, long term data• Disadvantages: expensive


Orlistat (Xenical, Alli)

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• MoA: pancreatic and gastric lipase inhibitor• Mean Loss: 2.9-3.4 kg over 1 year• CI: levothyroxine intake, warfarin, antiepileptic drugs,

cyclosporin (2 hours), chronic malabsorption, cholestasis• Common SE: steatorrhea, oily spotting, flatulence

w/discharge, fecal urgency, fecal incontinence• Advantages: non systemic• Disadvantages: less weight loss, side effect profile


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Naltrexone/bupropion (Contrave)

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• MoA: opiod antagonist/norepinephrine and dopamine reuptake inhibitor

• Mean Loss: 4.8% over 1 year• CI: uncontrolled HTN, SZ, anorexia or bulimia, drug or

alcohol w/d, MAOi• Common SE: nausea, constipation, HA, vomiting,

dizziness• Advantages: greater weight loss, food addiction• Disadvantages: side effects


Liraglutide (Saxenda)

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• MoA: GLP-1 receptor agonist• Mean Loss: 5.8 kg over 1 year• CI: MTC or MEN2 history• Common SE: nausea, vomiting… pancreatitis• Advantages: low side effects• Disadvantages: expensive, injectable


Metformin (off-label)

6 3DPP. Diab Care 2012; 35(4): 731-737.

Learning Objectives

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My Note Template

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• Your stated goal weight is ***. We know our plan is working when you have lost 5% of your body weight over three months.

• We have discussed bariatric surgery today. ***

• General patient education • Importance of long-term maintenance treatment in weight loss• Use non-food self-rewards to reinforce behavior changes• Elicit support from others; identify saboteurs

• Diet Goals: {obes diet:16548}• TRACKING YOUR INTAKE IS ESSENTIAL SO YOU HAVE RECORD OF WHAT YOU ARE DOING• Careful meal planning; avoiding ad hoc eating• Stimulus control to control unhealthy eating•• Activity Goals: • Informal measures, e.g. taking stairs instead of elevator• Formal exercise regimen:***•

My Note Template Cont’d

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• Medications:• -metformin 500 mg orally twice daily with meals for a week then• 500 mg po daily with breakfast and 1000 mg PO daily with supper for a week then • 1000 mg po daily with breakfast and 1000 mg PO daily with supper thereafter• *if any of these doses cause gastric upset, go back to the dose that didn't • -{Meds:38942}• We recommend discontinuing the following medications if possible as they are linked to weight gain: ***• Recommended alternatives to consider are: ***•• Other behavioral treatment: {obes behav:16539}•• Other treatment: {other tx:16541}•• Follow up visit with @PCP@ recommended in 1-2 months• Follow up weights, BP and HR at @PCP@'s office, at home, your pharmacy or weight management clinic every 1-2 weeks. Please let me know if you are not losing weight.• Follow up with Asma Al-Zougbi, MD in 3 months at which time we will reassess the need for alterations to diet and exercise

plans, medication or procedures based on the response to today's interventions.• WEIGHT LOSS IS NOT EASY. THERE IS NO "ONE SIZE FITS ALL" PLAN. BE KIND TO YOURSELF BUT KNOW THAT YOU

CAN DO IT. LET ME KNOW IF YOU FEEL YOU ARE "FALLING OFF OF THE WAGON" AS WE CAN WORK TOGETHER TO GET YOU BACK ON IT!

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Case 1: Visit 1

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• 27 y.o. female with obesity and migraines presents to your clinic to discuss weight loss. She states she was slightly overweight as a child and teenager, but gained weight after getting married in 2013 and has been gaining since then.

• 24 Hour Food Recall:– Banana and Breakfast Essentials shake– pretzels– Turkey burger with shredded cheese and sour cream– PB sandwich– Two regular Gatorade

Case 1: Visit 1

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• Activity: housework, walks 2-3 times a week for around 20 minutes with the baby in a stroller

• Other: Eats 3 meals and 1-2 snacks a day, relatively consistent with timing, she does the food shopping and she and her husband prepare meals, not a stress eater.

• No meds that cause weight gain, no excess alcohol use, mild anxiety

• No complications of obesity• Works in an office

Case 1: Physical Exam

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• BP 109/83 | Pulse 93 | Temp(Src) (°F) 97.9 (36.6) (Tympanic) | Resp 16 | Ht 157.5 cm | Wt98.2 kg | BMI 39.59 kg/(m^2) | SpO2 (%) 96

• Patient looks healthy and comfortable and appears stated age.• Pupils are equal and reactive and normal extraocular muscle movements.• Mucous membranes are moist and patient has no oropharyngeal lesions. Acanthosis

negricans. No dorsocervical fat pad.• Neck is supple. No thyromegaly and no thyroid nodules.• No cervical or supraclavicular lymphadenopathy.• Heart is regular with no murmurs.• Lungs are clear to auscultations bilaterally.• Abdomen is soft and nontender, no hepatosplenomegaly or masses.• Extremities are without edema, clubbing or cyanosis. • 5+ motor strength. • Skin is of normal texture and temperature. No thinning or bruising and no wide

striations.

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Case 1: Goal Setting

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• She tells you her goal weight is 150 lbs in the long term, and her short term goal is 200 lbs.

• Diet: stimulus control, careful meal planning, 1400 calorie diet

• Activity: She wants to join Fitness and Friends and will go three times a week for at least 30 minutes after work. Her husband will watch the baby.

• Pharmacotherapy: Metformin (off label) to be titrated up to 1000 BID AC

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Case 1: Visit 2

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100

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1 60

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Jun-1 8 Ju l -18 Aug-1 8 S ep -1 8 Oc t-18 Nov-1 8 De c-1 8 Ja n-1 9 F eb -1 9 Mar -19 Ap r-19 May -1 9 Jun-1 9

Wei

ght(

lbs)

Weight

TopiramateMetformin

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Case 1: Visit 2

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• Address what it working and not working (1400 calorie diet, MyFitnessPal, exercising 3 times a week).

• Address if any complications are better or worse (migraines better).

• Address side effects of medications.

Case 1: Visit 3

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100

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1 40

1 60

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2 20

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Jun -18 Ju l -18 Aug-1 8 S ep -1 8 Oc t-18 Nov-1 8 De c-1 8 Ja n-1 9 F eb -1 9 Mar -19 Ap r-19 May -1 9 Jun -19

Wei

ght(

lbs)

Weight

TopiramateMetformin

Case 1: Visit 4

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100

1 20

1 40

1 60

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2 20

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Jun-1 8 Ju l -18 Aug-1 8 S ep -1 8 Oc t-18 Nov-1 8 De c-1 8 Ja n-1 9 F eb -1 9 Mar -19 Ap r-19 May -1 9 Jun-1 9

Wei

ght(

lbs)

Weight

Topiramate

Naltrexone

Metformin

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Case 1: Visit 4

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Ju n -18 Ju l -18 Au g-1 8 S ep -1 8 Oc t-18 No v-1 8 De c-1 8 Ja n-1 9 F eb -1 9 M ar -19 Ap r-19 M ay -1 9 Ju n -19

Wei

ght(

lbs)

Weight

Topiramate

Naltrexone

Metformin

150 lbs

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Take Home Points

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• Obesity is a long-term, complex disease that requires long-term, complex management.

• Let the patient determine the goal and path- you are their guide, not their drill sergeant.

• Utilize the 4 pillars in the management of patients with obesity: diet, activity, behavior and pharmacotherapy.

• Tailor pharmacotherapy to the unique characteristics of your patient.

• Reassess frequently and change course as needed.

Guidelines and Resources

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• Pharmacological Management of Obesity: An Endocrine Society Clinical Practice Guideline (2015)

• 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults

• Obesity Medicine Association Algorithm QUESTIONS

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AlZougbiAsma.2019 IPAS Evaluation and Mangement of …...9/23/19 1 Asma Al-Zougbi, MD, MME IPAS 2019...

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