Ms Miriam MullardLead Dietitian

MacMurray Centre

Auckland

8:30 - 9:25 WS #95: The Weight Loss Menu

9:35 - 10:30 WS #107: The Weight Loss Menu (Repeated)

Dr Alasdair PatrickGastroenterologist and General Physician

Middlemore Hospital

Auckland

The only fully comprehensive

Gastroenterology center in Auckland

Opened in 2009

Largest Gastro practice in NZ

12 Gastroenterologists

1 Paediatric Gastroenterologist

1 Hepatologist

4 Surgeons

Dietician

Full diagnostic facilities on site

Dr Alasdair Patrick

Gastroenterologist

The weight loss menu

Dr Alasdair Patrick

MacMurray Centre

Miriam Mullard

MacMurray Centre

The Weight loss menu

Background

Diet and exercise (Miriam)

Behavioural modification

Pharmacological treatments

Endoscopic treatments:

- Overview

- Intra-gastric Balloons

- Endoscopic sleeve gastroplasty

Conclusion

Obesity

Obesity: Adults by Ethnic Group

• NZ third highest obesity rate in OECD

• Adult obesity rate increased from 27% in 2006/07 to 32%

in 2015/16

• 35% adults are overweight but not obeseP

erc

en

tag

e (

%)

(BMI >30Kg/m2), age >15 yrs

MOH statistics 2016

Obesity

Obesity: Adults by Ethnic Group

• NZ third highest obesity rate in OECD

• Adult obesity rate increased from 27% in 2006/07 to 32%

in 2015/16

• 35% adults are overweight but not obeseP

erc

en

tag

e (

%)

(BMI >30Kg/m2), age >15 yrs

MOH statistics 2016

Diabetes

>35% rise in prevalence of Type II DM over the last

decade

Prevalence in Maori and Pacific Is 3x higher, increasing at

a faster rate than Europeans

Increasing burden due to obesity epidemic, aging

population and ethnic mix

Gastrointestinal and Hepatic

Morbidity associated with Obesity

The Cost of Obesity?The Medical cost of Obesity in North

America

$US 210 Billion/ year

In 2012 it was estimated to cost NZ $722-$849m per year

Liver and Obesity:

NAFLD

Mortality in Patients With NAFLD

Patients with NAFLD (N = 420) matched by age and sex to

general population, followed for 7.6 ± 4.0 yrs

Adams LA, et al. Gastroenterology. 2005;129:113-121.

Top 3 Causes of

Death in NAFLD, %

Patients

(n = 53)

Malignancy 28

Ischemic heart disease 25

Liver disease 13

Survival at 10 Yrs

General population: 87%

Patients with NAFLD: 77%

Log-rank P < .005

0

20

40

60

80

100

0 4

Surv

ival (%

)

62 10

General populationPatients with NAFLD

P = .03

Yrs

8 12 14 16

Current Management of NASH

Weight loss Target 7-10%

ExerciseControl

metabolic risk factors

No long term data on Vit-E and Pioglitazone

No approved therapy for the treatment of NASH

Summary Obesity is the major epidemic of our lifetime

Diet and Exercise

Miriam Mullard

NZ Registered Dietitian

MacMurray Centre

It’s not enough to tell them what to do,

we need to show them how to do it.

Information does not always drive behaviour

Factors affecting

food choice

Lack of support at

home

Cost of Healthy Food

Limited skills and

experience

Being trapped at

home

Partner controlling

food choices

Need to avoid waste

(Barker et al., 2008)

Motivate patients to find their own solutions

Multi component interventions lead to greater

weight loss

Behaviourmodification

Lifestyle Information

Kirk et al. Int J of Obes. 2012; 36. 178-

185.

Rose et al. Int J Obes. 2013;

37(1):118-28

Ask to hear their story

Tailor interventions to your patient

Improve dietary quality

Regulate meal

frequency and

pattern

Reduce portion Sizes

Eat Mindfully

Monitor Diet

Ask clients to name one

thing they can change

Encourage your clients to take control

•Plan meals ahead of

time

•Eat regular meals and

snacks

•Plan ahead for busy

times

•Identify ‘danger’ times

when likely to overeat

Promote regular self monitoring

Apps for self monitoring

Use the healthy plate model to explain portion

control

Encourage patients to eat mindfully

Disordered eating

results from a

disconnect between

appetite and physical

needs

Mindful eating is about

paying attention and

slowing down. Source: Eat, Drink, and Be

Mindful by Susan Albers

Mindfulness Apps

Calorie restriction is more important than exercise

for weight loss

High levels of activity are needed to achieve

weight loss

NICE (2014) Obesity: identification, assessment and

management

Maintaining and improving

health

150 minutes per week

To prevent obesity 45-50 minutes moderate

intensity a day

Prevention of weight gain

after weight loss

60-90 minutes per day

Exercise

improves

health

even

without

weight

loss

Make sure that goals ARE achievable

Reduce Sedentary Behaviours

Encourage Self

Monitoring

Suggest Apps

Exercise on Referral

It’s not enough to tell them what to do,

we need to show them how to do it.

Thanks Miriam

Primary care

Weight loss advice by primary care providers has a

significant positive impact (OR 3.85)

Multiple component interventions lead to greater

weight loss; ie three component interventions: diet,

exercise and behavioural therapy were more likely to

be successful

Kirk et al. Int J of Obes. 2012; 36. 178-185.

Rose et al. Int J Obes. 2013; 37(1):118-28

Diet

Low energy, VLCD, low glycaemic index diets all

achieve similar weight loss ~4kg at 1yr

Low carbohydrate vs low fat diets, no significant

difference in weight loss. (7.25Kg vs 7.27Kg, p=ns).

Meta-analysis; no specific diet identified for healthy

obese patients

Vink et al. Obesity. 2016 Feb;24(2):321-7.

Johnston et al. JAMA. 2014; 312(9):923-33

Stelmach-Mardas et al. Nutrients. 2016; 28; 8(8).

Exercise

150-250 mins/week moderate intensity exercise will

only produce modest weight loss

>250mins/week associated with clinically significant

weight loss

BUT: health status is improved even in the absence of

weight loss (improved BP, lipids, insulin resistance).

Exercise results in improved weight loss maintenance

at 1 yr.

Weight Loss in NASH

Randomized 2:1 ratio to receive intensive lifestyle intervention (LS) or structured education (control) for 48 weeks.

LS group lost an average of 9.3% TBW versus 0.2% in the control group (p=0.003).

LS group reduction of NAS of at least 3 points or had post treatment NAS ≤ 2 compared with the control group (72% versus 30%, p=0.03).

Participants who achieved the study weight loss goal (>7%), had significant improvements in NAS (P < 0.001).

Pomrat et al. Hepatology 2010

Pharmacologic Management

of Obesity

Weight loss drugs

Only recommend if:

- No significant improvement with >6-months

lifestyle changes

- BMI >30kg/m2. (or >27Kg/m2 with at least one

weight related disease)

FDA approved five ‘long-term’ weight loss drugs:

- Orlistat, Lorcaserin, Naltrexone-bupropion,

Phenteramine-topiramate, Liraglutide.

Orlistat

FDA approved 1999

Gastrointestinal lipase inhibitor; preventing dietary fat

(`30%) from being metabolized and absorbed

Continue >3-months only if >5% TBW loss

Adverse effects; oily stool, faecal urgency, increased

flatus

Outcome

Meta-analysis: 1-year weight loss ~3.4Kg

Associated reduction in lipids, BP, fasting glucose

<10% patients will take for a year due to GI

side effects

Phentermine (Duromine)

FDA approved 1959

Sympathomimetic amine, a stimulant that acts on the

CNS and suppresses appetite.

(Combined with low-dose topiramate; associated with

increased appetite suppression; off-label use in NZ)

Starting dose 15mg, maintenance 30mg mane

Adverse effects: tachycardia, HT, insomnia, irritability,

headache, nausea, altered bowel

Outcome

6-months; wt loss 4.5kg (>placebo), 46% lost >5%

TBW

Topiramate

FDA approved 1996 for epilepsy

Used in combination with phentermine (3.75/23mg, 7.5/46mg,

11.25/69mg, 15/92mg).

Adverse effects: paresthesia, insomnia, constipation, impaired taste

Outcome: Phentermine-topiramate over 1yr

6.6- 8.6kg (>placebo)

Reduction in progression to DM

Use of Topiramate in NZ would be off label.

(dose available 25, 50 and 100mg)

Other Medications: FDA

Lorcaserin: 5-HT-2C agonist, binds serotonin 2C

receptor in hypothalamus, reducing appetite.

weight loss: 3.6% TBW.

Naltrexone/Bupropion: opioid antagonist + dopamine and

NA reuptake inhibitor.

weight loss: 4.8% TBW

Black Box Warning: suicidality patients <24yrs age.

Liraglutide: mimics GLP-1. Reduces appetite, delays

gastric emptying . FDA approved for treatment of DM

weight loss: 6% TBW (3mg daily)

Medical Therapies

Mean Weight Loss Dropout Rates

Endoscopic Management of Obesity

The Cost of Obesity?

Gastric Physiology

Obesity is associated with decreased satiation. For

every 5 kg/m2 of increase in BMI, there is a 50kcal

higher consumption before sensing fullness

Higher BMI associated

with greater fasting

gastric volume and

accelerated gastric

emptying

Restrictive endoscopic procedures Intragastric balloon Bioenterics Consecutive Balloon (Bioenterics Corporation, Carpentry, Allergan Inc., Irvine,

CA, USA)/Orbera Intragastric Balloon (Apollo Endosurgery, Austin, TX, USA)

Ullorex Oral Intragastric Balloon (Obalon Therapeutics, Inc., San Diego, CA, USA/ Phagia

Technologies, Inc., USA)

Spatz Adjustable Intragastric Balloon (SpatzGFAR, Inc., NY, USA)

Heliosphere Bag (Helioscopie Medical Implants, Vienna, France)

Pear-shaped Semistationary Antral Balloon (JP Industria Farmacéutica S.A., Brazil) [17]

Silimed Gastric Balloon (Slimed, Rio de Janeiro, Brazil)

Endogast-Adjustable Totally Implantable Intragastric Prosthesis (Districlass Medical S.A.,

France)

Endoscopic gastroplasty techniques Intragastric gastroplasty EndoCinch™ (C.R. Bard Inc., Murray Hill, NJ, USA)

TOGA system (Satiety Inc., Palo Alto, CA, USA)

Esophyx (Boston Scientific Corp., Natick, MA, USA)

KUMC Successive Suturing Device (Korea University, Seoul, Korea)

Overstitch endoscopic suturing system (Apollo Endosurgery, Austin, TX, USA)

G Prox (USGI Medical, San Clemente, CA, USA)

NDO plicator (NDO Surgical, Mansfield, MA, USA)

OTSCs (Aponos, Kingston, NH, USA)

Incisionless Operating Platform (IOP; USGI Medical, San Clemente, CA, USA)

Malabsorptive endoscopic procedure Malabsorptive stent Endobarrier (GI Dynamics, Inc., Watertown, MA, USA)

ValenTx device (ValenTx Inc., Carpinteria, CA, USA)

SatiSphere (Endosphere Inc., Columbus, OH, USA)

Evolving bariatric endoscopic technique Aspiration therapy Gastro electrical

stimulator

Aspire Assist (Aspire Bariatrics, King of Prussia, PA, USA)

Enterra/Transcend Implantable Gastric Stimulator (Transneuronix Inc. and Enterra Therapy

System, Medtronic, Minneapolis, MN, USA)

Endostim (EndoStim BV, The Hague, Netherlands)

Intrapace Abiliti Gastric Stimulator (Menlo Park, CA, USA)

Maestro VBLOCK therapy system (EnteroMedics, MN, USA)

the Diamond/Tantalus II system (Metacure, Kfar-Saba, Israel)

Title Type procedure Product

EndoBarrier

Meta-analysis: 12-month EWL 35.3%

RCT EndoBarrier (vs Sham)

HBA1c -1.7

Recent trial terminated 325/500 patients due to 3.5% hepatic

abscess formation. Early device retrieval in 10.9%

Second generation device undergoing trials

Small Bowel Interventions

Duodenal resurfacing Self-assembling magnets

Intragastric Balloons

Intragastric Balloons

First generation IGBs were air-filled, associated

severe complications, spontaneous deflation

Fluid filled IGBs have partly resolved concerns

IGB RCT: Meta-analysis

20 RCTs, 1195 patients (Saber et al)

- 3-month effect: BMI reduction 1.59kg/m2, or

14.25% EWL, or 4.6Kg weight loss (compared to

control group- behavioural modification, and sham

procedure)

16 Studies; 3068 patients (Imaz et al)

- Overall Weight loss: 14.7Kg, reduction BMI

5.7Kg/m2 and 32.1 %EWL at 6-months

Saber et al. Obes Surg 2017; 27: 277-87

Imaz et al. Obes Surg 2008; 18 (7): 841-6

Safety

Saber et al. Obes Surg 2017; 27: 277-87

Intra-Gastric Balloons

Obera Spatz3

Placed under sedation

6-month duration

Median weight loss:

14-15Kg

Placed under deep

sedation

Adjustable

12-month duration

Median weight loss:

23-24Kg

Effect of IGBs on Liver Enzymes

Popov et al. DigDisSci 2016; 61: 2477-87

Effect of IGBs on Liver Enzymes

Popov et al. DigDisSci 2016; 61: 2477-87

ALT decreased by -10 U/l, GGT decreased -9.8 U/l

BMI reduction 4.98 kg/m2

Hepatic steatosis improved at 6-months on MR

NAFLD Score lower (2 vs 4, p=0.03)

Endoscopic Sleeve Gastroplasty

(ESG)

Background

• Bariatric interventions offer a more efficacious and

durable weight loss than non-surgical approaches

• Surgical weight loss procedures are limited by

appeal, availability, cost and short and long term

risks

• Endoscopic Sleeve Gastroplasty is an incisionless,

minimally invasive technique

• Clinically significant improvements in obesity related

co-morbidities are higher when %TBWL exceeds

10%.

(lifestyle intervention typically results in 3-5% TBWL)

Procedure

ESG reduces the volume

of the stomach (~80%)

using a series of

endoscopic sutures (5-

8x)

The final shape of the

stomach resembles a

traditional sleeve without

the need to amputate the

greater curvature, thus

less invasive

Patient Selection and Exclusion

Recommendations

Age: 18-65+

BMI: 30-40 (BMI is not limited to 40. The IFSO/OSSANZ bariatric guidelines are followed)

Compliant with prescribed diet, aftercare instructions

Exclusion RecommendationFamily history of Stomach Cancer

Hiatus hernia >5cm

Previous gastric surgery

Gastric ulceration

Cirrhosis

Pregnancy or plans of pregnancy in the next 12 months

Coagulation disorders or chronic use of anticoagulants***

Any active medical condition that would preclude a safe endoscopic suturing repair

***at the discretion of the treating physician

ESG for Obesity: a Multicenter Study of

248 patients with 24-months Follow-Up

• Mean age 44y, 73% female.

• Baseline BMI 37.8 (+/- 5.6 Kg/m2)

Weight Loss (%TBWL)

6-months 15.2% (95% CI 14.2- 16.3)

24-months 18.6% (95% CI 15.7- 21.5)

Results

Lopez-Nava et al. Obes Surg Apr 2017

Endoscopic Sleeve Gastroplasty;

1-year Follow-Up

Results

Changes in weight loss post ESG

Adverse Events

No major events or bleeding complications

Post discharge pain 50%, and nausea 20%

Variable 1-month 3-months 6-months 12-months

BMI loss (kg/m2) 2.8 +/- 0.8 4.9 +/- 1.6 6.9 +/- 2.9 7.3 +/- 4.2

Total Weight loss 7.9 +/- 2.7 14.1 +/- 5.5 19.6 +/- 9.1 21.1 +/- 12.6

% TBWL 7.4 +/- 2.3 12.9 +/- 4.3 17.8 +/- 7.5 18.7 +/- 10.7

% EBWL 24.0 +/- 11.8 40.5 +/- 16.5 53.9 +/- 24.8 54.6 +/- 31.9

Lopez-Nava End Int 2016

Endoscopic Sleeve Gastroplasty;

1-year Follow-Up

Barium study, 1-year post ESG.

Arrows show suture plications

Endoscopic view, 1-year post ESG

Lopez-Nava End Int 2016

Endoscopic Sleeve Gastroplasty: Gastric

Physiology

25 patients underwent ESG. BMI 30- 40 Kg/m2

Results

Delayed gastric emptying of solids, ~50% increase in time for gastric

emptying

4-Hr post meal 32% meal retained in gastric fundus

No significant change in gastric emptying of liquids

Endoscopic Sleeve Gastroplasty: Gastric

Physiology

Results

ESG increases satiation with a 59% decrease in

calorie intake to reach maximum fullness (meal

tolerance test)

Postprandial ghrelin levels decreased by 29.4% (no

statistically significant changes in leptin, GLP-1 and

PYY)

Insulin sensitivity improved (HOMA-IR reduced by

>30%)

Endoscopic Sleeve Gastroplasty

ESG is an effective and durable treatment for

weight loss

Weight loss at 2 years ~18-20% TBWL

Low morbidity

Successful weight loss requires a multidisciplinary

approach

Endoscopic Sleeve Gastroplasty

ESG is an effective and durable treatment for

weight loss

Weight loss at 2 years ~18-20% TBWL

Low morbidity

Successful weight loss requires a multidisciplinary

approach

Available at the

MacMurray Centre

Conclusions

Obesity and obesity related complication

prevalence is rapidly increasing.

A multidisciplinary and population based approach

is required.

- Diet, exercise and behavioural management

- ?Pharmacologic treatments

- Endoscopic treatment:

Intra-gastric balloon

Endoscopic sleeve gastroplasty

- Surgical treatment

The only fully comprehensive

Gastroenterology center in Auckland

Opened in 2009

Largest Gastro practice in NZ

12 Gastroenterologists

1 Paediatric Gastroenterologist

1 Hepatologist

4 Surgeons

Dietician

Full diagnostic facilities on site