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

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.

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

Trends in Obesity Prevalence 1976-2010

Determining Treatment

BMI Treatment

25-26.9 Healthy Lifestyle

27-29.9 Healthy Lifestyle; Medications if additional risk factors

30-39.9 Intensive Behavioral Therapy; Medications; Surgery if BMI > 35 and co-morbidities

> 40 Intensive Behavioral Therapy; Medications; Surgery

Treatment Options

Correct underlying metabolic problems Diet, exercise, behavioral therapy Medications

Optimize current medicationAnti-obesity medications

Bariatric Surgery

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

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

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

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)

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)

Medicare Coverage for Obesity Intensive Behavioral Therapy (G0447)

Primary care physician or NP/PA/certified

clinical nurse specialist- face-face x 15 minsUp 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 monhts5A’s: Assess, Advise, Agree, Assist, ArrangeNot separately payable with another encounter

Medicare CodesBMI ICD-9 ICD-10

30-30.9 V85.30 Z68.30

31-31.9 V85.31 Z68.31

: : :

39-39.9 V85.39 Z68.39

40-44.9 V85.41 Z68.41

45-49.9 V85.42 Z68.42

50-59.9 V85.43 Z68.43

60-69.9 V85.44 Z68.44

> 70 V85.45 Z68.45

5 A’s ExamplesAssess “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.”

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)

Drug AlternativesAntidiabetic agentsInsulin; meglitinides; sulfonylureas (glyburide, glipizide); thiazolidinediones

Acarbose (Precose); exenatide (Byetta); glimepiride (Amaryl); metformin (Glucophage); miglitol (Glyset); pramlintide (Symlin)

Neurologic agentsAnticonvulsants (valproic acid [Depakene], gabapentin [Neurontin], carbamazepine [Tegretol]); lithium

Lamotrigine (Lamictal); topiramate (Topamax); zonisamide (Zonegran)

Optimize Medications

Drug Alternatives

Psychiatric agentsAntipsychotics (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

Drug AlternativesBlood pressure agentsAlpha-adrenergic blockers

Beta-adrenergic blockers (especially propranolol)

Doxazosin (Cardura)

Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers; calcium-channel blockers; selective beta blockers

Othercorticosteroids Acetaminophen; nonsteroidal

anti-inflammatory drugs

Medications

Orlistat (Xenical, Alli)Lipase inhibitor: inhibits fat absorption120 mg tid during or up to 1 hour after mealSide 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

Medications

Phentermine-topiramate (Qsymia)Low dose: 7.5 mg/46 mg 8.0% weight lossHigh dose: 15 mg/92 mg 10.5% weight lossSide effects: increased heart rate, palpitations,

drowsiness, paresthesias, memory loss, confusion

Contraindicated in pregnancy (orofacial cleft)

and recent/unstable CAD or CVDRisk evaluation and mitigation strategy (REMS)

Medications

Lorcaserin (Belviq)10 mg bidselectively activates 5-HT2C receptors on

anorexigenic neurons in the hypothalamus decreases eating and promotes satiety

4.5% - 5.8% weight lossSide effects: headache, dizziness, fatigue,

drowsiness, nausea, dry mouth, constipationContraindicated pregnancy, caution CHF

Bariatric Surgery

Number of Bariatric Surgeries Performed

American Society for Metabolic and Bariatric Surgery

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

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

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

Silicone band

Encircles proximal stomach

Purely restrictive procedure

Adjustable Gastric Band

Roux-en-Y Gastric Bypass

20 to 30 cc pouch

Disconnected

pouch-stomach

~ 1 cm diameter

outlet

Intestinal bypass of

either 75 to 150 cm

+/- Cholecystectomy

The Foregut TheoryExclusion of Duodenum from transit of nutrientsprevents secretion of signal that promotesinsulin resistance and DM type 2

Rubino F. Annals of Surgery • Vol 244, Nov 2006

A gastric tube of 60 to 120mL is created

Induces weight loss by 2 mechanisms:1) Mechanical restriction2) Hormonal modification

Sleeve Gastrectomy

%EWL 57 %New GERD 21 % (3% preop)Leak 4.9 %Mortality 0

Himpens J. Ann Surg 252: 319–324 2010

n=53, av. follow-up 6 yrs

Sleeve Gastrectomy Long Term results

Tice J. Am J Med. Vol 121, 10. 2008

Resolution

%

Preoperative Morbidity

■ Bypass

■ Band

DM DyslipidemiaHTN OSA

908070605040302010

Bypass versus Band

Band%

Sleeve%

Bypass%

%EWL 49 57 63

DMRemission

47 63 83

Mortality 0.2 1 0.6

Morbidity 33 9 7

Vit Def 0 32 58

Comparison of Bariatric Surgery

Buchwald, H. JAMA 2004

Meta Analysis

Bariatric Surgery versus Intensive Medical Therapy

Schauer P, NEJM 2012

Change in BMI

Intensive medical therapy

Gastric Bypass

Gastric Sleeve

Long-Term Management after Bariatric Surgery

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

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

Laboratory Testing

Follow-up period Laboratory TestsEvery 3 months x 1 year CBC, glucose, creatinineEvery 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

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

SupplementsSupplement 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 po500 mcg/day SL1000 mcg IM monthly

Vitamin D 400 to 800 IU/day 2,000 IU daily

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