Treatment of ObesitySAJIDA AHAD

MERCY GENERAL SURGERY

Objectives

1. Learn classification and evaluation of overweight and obese patient

2. Discuss impact of voluntary weight loss on morbidity and mortality

3. Review resources for treatment of obesity in primary care setting

4. Update on bariatric surgery

Why care about obesity?

Obesity is a global public health concern

Prevalence of obesity in the United States: 35% among men and 40% among women Compared to 25 years ago when less than 15% of the nation was considered obese

The obesity epidemic has placed an economic burden on the US health care system

In 2013, obesity was officially recognized as a disease state by the American Medical Association

World Health Organization (WHO) defines body mass index (BMI)as follows Normal = 18.5 to 24.9

Overweight =25 to 29.9

Obese >30

class I =30 to 34.9

class II =35 to 39.9

class III = 40 and above

Classification and evaluation of

overweight and obese patients

Clinical classification

Size and number of fat cells

In adults, upper limits of the total of normal fat cells range from 40-60 billion

The number of fact cell increase most rapidly during late childhood and puberty

The number of fat cells can increase 3-5 fold with obesity occurs in childhood or adolescence

Hypertrophic obesity

Large fat cells correlate with android or truncal fat distribution

This condition is often associated with metabolic disorders such as glucose intolerance, dyslipidemia,

hypertension and coronary artery disease

Fat distribution

Fat distribution is important because increased visceral fat predict the development of health

risks better than total body fat

Waist circumference

CT

MRI

Waist circumference(WC)

WC has been shown to be a strong correlate of intra-abdominal adipose

tissue in diverse race/ethnic groups

WC is very strongly related to total adiposity and Visceral adiposity

Visceral fat is associated with many metabolic risk factors, metabolic

syndrome, diabetes, and CAD

cutoff values for WC (90 cm for men and 83 cm for women) that are equivalent to a BMI of 25 kg/m2 might represent appropriate action levels

for counseling patients to limit further weight gain

Natural history of obesity

Individuals can become overweight at any age

One third of the overweight adults do so before age 20

Predictors of weight gain

Incidence of diabetic mother R mother who smoked

Overweight parents

Overweight in childhood

Lower education or income group

Cessation of smoking

Sedentary lifestyle

Low metabolic rate

Lack of maternal knowledge of child’s sweets eating habits

Recent marriage

Multiple births

Cost of obesity

The economic cost of obesity

The cost-effectiveness of treatment modalities

Economic cost of obesity

Direct Medical Cost

-direct treatment of obesity and related disease e.g. DM and HTN

-include medications and surgical procedures

Direct Non Medical Cost

-expense of health education

-expense of maintaining healthy life style

-preventing obesity

-not paid for by healthcare systems

Indirect Cost

-time lost from employment

-time lost by family and friends

Cost of Obesity (contd)

In USA, estimated cost of obesity ranges from $26.6 to $ 70 Billion

Upto 7 % of annual healthcare expenditures

Majority of the cost is treating obesity related conditions rather than obesity itself

Cost to employers

❑ Medical charges for obese employees 69% higher than non obese employees

❑ Obese employees use twice as many sick leave days as normal weight employees

Cost to individuals

❑ Shorter life expectancy

❑ Lower health related quality of life

❑ Cost of weigh management and control($66 billion market)

Cost effectiveness of obesity

interventions

A physician weight loss advice is associated with both fewer calories and

fat intake and more exercise to lose weight

Weigh WatchersTM might be cost-effective because of its demonstrated

effectiveness and the moderate cost

Medically supervised programs are expensive, but achieve more weight

loss than Weight Watchers in the best scenario

Although there is insufficient evidence for the effectiveness of weight loss

of inexpensive self-help programs and Internet-based programs, they are

potentially cost-effective if the weight loss goal can be achieved

Voluntary weight loss

voluntary weight loss is considered central to the clinical and public health

response to prevent obesity

Barriers

1. Perceived ineffective

2. Epidemiological concern with increased mortality

3. Broad ramifications

more than a 1/3 adults and more than 2/3 obese adults are trying to lose weight at

any given time

huge potential of interventions to positively affect health or, waste resources

Strategies for voluntary weight loss

used by patients

most people have a weight loss goal of <10 kg, but about one-fourth would like to lose 15 kg or more

only one-fifth report the recommended combination of eating fewer calories and exercising >150 min/wk

other methods used

▪ skipping meals (17%)

▪ attending special programs (7%)

▪ eating special products (22%)

▪ taking supplements or diet pills (14%)

▪ fasting(3%)

▪ purging (3%)

structured weight loss programs

advantage of providing stronger evidence about the cause and effect,

dose response, and clinical utility of weight loss interventions

limitation is that it frequently test interventions that are either not practical

in the real world and/or do not reflect the real ways that people in the

community go about weight loss

Unknown net effect in the population

Effect on diseases

Weight loss affect long-term disease incidence and mortality

most direct and important effects on insulin sensitivity, glucose tolerance, blood pressure, lipid parameters, and inflammatory factors

A 5 kg reduction in weight causes

▪ Drop of 4 mmHg systolic blood pressure

▪ Drop of 3 mmHg of diastolic blood pressure

▪ Decrease of 5 to 8 mg/dL of total and low-density lipoprotein (LDL) cholesterol

▪ Decrease of 18 mg/dL of triglyceride

Weight loss reduces left ventricular hypertrophy , resting heart rate, increases stroke volume and cardiac output, improves coagulation and fibrinolytic factors, reduces angina symptoms, and consistently improves functional status

Decrease in inflammatory markers

Improvement in HbA1c

Is short term weight loss beneficial?

most people who try to lose weight regain weight

on average, one-third of peak weight loss is regained in the year following weight loss

unclear whether the physiological benefits are maintained over a long-enough period of time to reverse preexisting pathology and thus influence long-term health outcomes

weight loss is associated with increased bone loss, decreased lean muscle mass, gallstone development, and perhaps, decreased immunity associated with multiple weight loss attempts

The reduction in bone loss may be offset by increased physical activity, but concerning in older adults

Strong and consistent evidence relates intentional weight loss to reduced

incidence of diabetes among high-risk individuals

Intentional weight loss has been consistently associated with reduced

incidence of hypertension and improved control of blood pressure

Weight loss may reduce disability and improve mobility and functioning in

daily living among older populations

Increasing evidence suggests that intentional weight loss reduces overall

mortality and possibly CVD incidence

Obesity and Primary Care

Obesity is one of the most common medical problem seen by Primary

Care Physicians

these patients are also more likely to present with other diseases, e.g.,

hypertension, dyslipidemia, type 2 diabetes, metabolic syndrome

In practice, however, obesity is underrecognized and undertreated in the

primary care setting

Failure to adequately identify the overweight and mildly obese patient,

however greater recognition for the moderately to severely obese patient

less than half of obese adults are being advised to lose weight by health

care professionals

Office-Based Obesity Care

Health care system geared to treating acute care problems rather than

chronic conditions

Obesity is a chronic condition

Physical

environment

Accessibility and comfort, space, reading and

educational material

Equipment Large BP cuffs, large gowns, Step stools, higher

limit scales

Materials Educational handouts on diet, exercise,

medications, surgery, www.choosemyplate.gov

Tools Pre-visit questionnaires, Fitness trackers, apps

Protocols Return visit, medications, referral to

surgery,dietitian and psychologists

Treating obesity

Measure height and weight

BMI

Measure waist circumference

assess comorbidities

Look for causes of obesity including the use of medications

Is the patient ready and motivated to lose weight?

If the patient is not ready to lose weight, urge weight maintenance and manage the complications

If the patient is ready, agree with the patient on reasonable weight and activity goals and document

Involve other professionals(dietitians, therapists, structured programs)

Guide to selecting treatment

Treatment 25-26.9 27-29.9 30-

34.9

35-39.9 >40

Diet, exercise,

behavior therapy

With

comorbidities

With

comorbidities

+ + +

Pharmacotherapy + + +

Surgery With

comorbidities

+

Pharmacotherapy

Antiobesity pharmacotherapy should be considered as an adjunct to diet

and behavioral modification

facilitates weight loss or promote long-term weight maintenance

Potentially treat comorbid conditions associated with obesity, including

prediabetes, type 2 diabetes mellitus (T2D), obstructive sleep apnea,

hypertension, and dyslipidemia

expected weight loss from obesity pharmacotherapy is 5% to 10% of total

body weight (TBW)

For patients with severe obesity (class III), multiple medications , in addition

to surgical intervention may be considered

Phentermine

Phentermine was approved by the FDA in 1959

Most commonly prescribed short-term (up to 12 weeks) medication for

weight loss Phentermine is primarily

Standard adult dose is up to 37.5 mg daily before breakfast

Use lowest effective dose first

side effects: dizziness, dry mouth, difficulty sleeping, and irritability

Orlistat

Approved in 1999 by the

Orlistat alters fat digestion by inhibiting gastric and pancreatic lipases,

causing approximately 30% fecal fat excretion

Prescribed 3 times a day at a dosage of 120 mg to be taken with meals

A lower-dose formulation containing 60 mg per capsule is available over

the counter and sold under the brand name Alli

Side : bloating, flatulence, flatus with discharge, and fecal incontinence

reduces the absorption of fat-soluble vitamins(A, D, E, K), a multivitamin

supplement is advised when treating with this agent

Lorcaserin(Belviq)

Approved by the FDA in 2012 for long-term weight management

Selective serotonin 2c receptor agonist

decreases food consumptionand promotes satiety by selectively

activating the 5HT-2c receptor on anorexigenic POMC neurons located in

the hypothalamus

daily dose of 10 mg twice a day

Side effects : headaches, dizziness, and nausea, hypoglycemia(reduction

in diabetic medication dosage may be needed)

PHENTERMINE/TOPIRAMATE (QSYMIA)

Approved by the FDA in 2012

Phentermine increases norepinephrine in the hypothalamus, enhancing POMC neuron pathway signaling to increase alpha-MSH, which binds to melanocortin 4 receptor and suppresses appetite

The exactmechanism of action for weight loss with topiramate is not known

4 dosages:

3.75/23mg (starting dose)

7.5/46mg (treatment dose)

11.25/69mg

15/92 mg (maximumdose

a stepwise approach, starting at 3.75/23 mg once daily for 2 weeks before increasing to the recommended dose of 7.5/46 mg once daily

Further titration to a maximum dose of 15/92 mg once daily may be considered for individuals who do not achieve 3%weight loss after 12 weeks.

If 5% weight loss is not achieved after 12 weeks at 15/92mg per day, then phentermine/topiramate ER dose should be gradually reduced for discontinuation

Qsymia(contd)

Side effects: paresthesias,dizziness, dysgeusia, and dry mouth

Inform women of reproductive age about the increased risk of congenital

malformation during the first trimester of pregnancy

Liraglutide(Saxenda)

Glucagon-like peptide-1 (GLP-1) agonist

cause glucose-dependent insulin secretion from pancreatic beta cells to

lower glucose levels, suppression of glucagon secretion, and slowing of

gastric emptying

FDA approved in 2014

Dose up to 3.0 mg once daily

Side effects: nausea, vomiting, hypoglycemia and diarrhea, increased

lipase, abdominal pain,

NALTREXONE /BUPROPION

(CONTRAVE

FDA approved in 2014

Given the known individual effects of naltrexone and bupropion on

addiction (alcohol and smoking, respectively), a fixed combination was

hypothesized to induce weight loss through sustained modulation of

central nervous system reward pathways

Gelesis

Each capsule contains thousands of proprietary, biocompatible hydrogel particles synthesized with starting materials that are Generally Recognized as Safe by the FDA

capsules are taken before a meal with water, after which the small particles within the capsules hydrate and expand in the stomach and small intestine,triggering several important satiety and glycemic control mechanisms

built-in safety features:

(a) the volume it creates is limited by the amount of water consumed

(b) the hydrated particles, which are 2 mm in size, do not cluster or stick together and have similar elasticity (rigidity) as ingested food

(c) the particles partially degrade in the colon, releasing absorbed water

Pilot Human Study initiation is planned in 2019

Bariatric Surgery at Mercy Medical

Center

Numbers

Sleeve gastrectomy :113

Gastric Bypass: 22

Before325.3

LBS

After175 LBS

SUCCESS STORIES

Before After

Program Start Date

December 26, 2016

Program Start Weight –

325.3 lbs Starting BMI –

54.13

Sleeve Gastrectomy

May 30, 2017

Current Weight – 175 lbs

Current BMI – 28

Total Weight Loss 150.3 lbs

Starting Pant Size – 26

Current Pant Size – 10/12

Before258

LBS

After

150 LBS

SUCCESS STORIESProgram Start Date

July 10, 2017

Program Start Weight - 258 lbs

Starting BMI – 43.6

Sleeve Gastrectomy

November 28, 2017

Current Weight – 150 lbs

Current BMI – 25.08

Total Weight Loss 108 lbs

Starting Pant Size – 18/20

Current Pant Size – 6/8

Before442 LBS

After325.2 LBS

SUCCESS STORIES

Before After

Program Start Date

September 29, 2016

Program Start Weight - 442 lbs

Starting BMI – 56.75

Sleeve Gastrectomy

April 18, 2017

Current Weight – 325.2 lbs

Current BMI – 40.65

Total Weight Loss 116.8 lbs

Before

320 LBS

After135 LBS

Success Stories

Program Start Date

March 30, 2017

Program Start Weight - 320 lbs

Starting BMI – 54.08

Sleeve Gastrectomy

September 20, 2017

Current Weight – 135 lbs

Current BMI – 23.19

Total Weight Loss 185 lbs