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2015 WNA Northwoods Clinical Practice UpdateSession 2 ‐ Fighting Obesity – A Multidisciplinary Approach

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Obesity: Past, present, and future –separating reality from fantasy..

JAMES YOUNG, M.D.

SEPTEMBER 25TH 2015

Where are we going today? What is Obesity History of Obesity – when did the obesity

epidemic really begin? The epidemic is here – now what?

Lifestyle – Exercise, Nutrition – can we really DIYour way to health?

Commercial Options – CanJennyNutriSeattleSlimgenixWeight Watcherswork?

Medical Weight Management – Doctor alwaysknows best…right?

Procedural – Gadgets, Gizmos, and….the gut? Surgery – the last, best hope??

When being smart and skilled isn’t enough –fat shaming in the exam room.

Disclaimers:

I have no financial conflicts to report – Ihave not yet sold my soul to eitherpharma or device manufactures as yet

I am a bit sarcastic and more of a smartalec

I like to tell very bad jokes New Glarus Moon Man, Surly Furious,

and Summit Saga are tied for nature’smost perfect fluids

Taylor Swift is my Spirit Animal…

What is obesity?

WHO A medical condition in which excess

body fat has accumulated to the extentthat it has an adverse effect on health

Categorized in terms of Weight BMI – Defined as weight in kg/m2 OR

(pounds) 703/in2

What is obesity? Categories of Obesity:

Underweight – BMI < 18.5 Normal Weight – BMI 18.5-24.9 Overweight – BMI 25-29.9 Class I Obesity – BMI 30.0-34.9 Class II Obesity – BMI 35-39.9 Class III Obesity – BMI > 40

BMI 40-44.9 Morbidly Obese (WHOsubclassification of class III Obesity)

BMI 45 or more is Severely or Super MorbidlyObese (WHO Classification)

Sturm R (July 2007). "Increases in morbid obesity in the USA: 2000–2005". Public Health 121 (7): 492–6

Where it began??? We commonly like to think that the

modern obesity epidemic beganhere:


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Where it began??? Or here?

Where it began???

So did it really start with the advent ofMcDonalds, iPhones, and Xbox?

Where it began???Where it began???

I would argue that it began not with RayKroc, Steve Jobs, or Bill Gates.

The modern obesity epidemic beganhere… 200-225 million years ago

First warm blooded mammals appeared on Earth

1.5-2 million years ago Humans evolved from apes

Where it began???

Humans found themselves in an energypoor environment

When food was needed – it had to befound, killed, prepared and eaten – if itwas found at all

Bellisari A., Obesity Reviews, 2008 Mar;9(2):165-80.

Where it began?

Humans not designed to live in energyrich environments Have developed sophisticated

neurological, hormonal, anatomical, andphysiological mechanisms to maintain anddefend weight

Why?

To keep us from starving to death


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Where it began?

So Obesity is…..wait for it…….

Not a disease per se

Obesity is a misuse of an evolutionarymechanism to prevent starvation inmammals including us.

Kaplan, Lee M. "Body weight regulation and obesity." Journal of gastrointestinal surgery 7.4 (2003):443-451.

Where it began?

So why now? Because rather than having to expend

hundreds if not thousands of calories perday to simply stay alive

We now expend thousands of dollarsconsuming thousands of calories inexcess of what we need to survive

While at the same time expending fewercalories to maintain our survival

Can we set the wayback machine to the present Mr. Peabody? It would be fair to ask – so what? The past affects the present – you can’t

escape biology The neurochemical bias to defend weight

directly impacts EVERY SINGLE MODALITY we useto manage weight in the here and now

We are FORCING the body to do something it’snot supposed to do – lose and shed excessenergy that the brain has identified as beingessential to survival

This is the likely origin of the “weight wall” or“plateau” that many patients struggle withduring any effort at losing weight.

So now we know the problem and where it came from – now what?

Well first of all – let’s ask ourselves thisquestion?

If obesity is “what the body’s supposedto do” then why do we want to treat it atall?

Just because the body can do something doesn’t mean it should..

The deposition of fat in the human bodyin obesity is analogous to a humanhoarder


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So in biochemical and physiological terms –what does this look like?

Redinger, Richard N. “Fat Storage and the biology of energy expenditure” Translational Research 164.2 (2009) 52-60

SEE FULL PAGE at end of handout

Comorbidities of Obesity Hypertension Atherosclerosis/CAD Insulin Resistance Type 2 Diabetes Mellitus Hyperlipidemia Increased risk of Malignancy Depression Obstructive Sleep Apnea Cerebrovascular Disease/Aneurysm Intracranial Hypertension Depression

In plain terms – sustained chronic obesity ultimately is fatal..

So if we’re to fight a “battle of the bulge” what are our options?

Options for Weight Management

Commercial Weight Management

Medical WeightManagement

EndoluminalProcedures/Laparoscopic Adjustable Band

Vertical Sleeve GastrectomyRNY Gastric Bypass Surgery

7-10% Loss of EBW15-25 % loss of EBW

35-50% loss of EBW 65-80% loss of EBW

Lifestyle Modification

Commercial Weight Management

Weight Watchers

Jenny Craig

Nutrisystem

Seattle Sutton

Medifast

Programs produceincredible amounts ofweight loss in the initialphases up to 1 year afterstarting of the program

Unfortunately themaintenance phase isdifficult to maintain

Failure rate is 90-95%within 2 yrs

Attrition rates are highlong term


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Lifestyle Modification – the DIY of Bariatrics Atkins Ornish The Zone DASH Paleolithic South Beach Some version of low

carb/high protein Mediterranean diet Whatever else is en

vogue this week….

Aerobic Running, Biking,

Walking, Jogging,Rowing, Etc

Strength Training Combinations

Crossfit Orangetheory Fitness Bootcamps HIIT

So what is the one, true diet???

None of them are…..

Goals are sustainability

Calorie restriction to some extent You can gain weight on Atkins, Paleo, or

any other regimen if you consume excesscalories

What about exercise? The role of exercise in weight management Which is better – sustained physical

activity for 30-60 minutes OR 3-5 smallshort bursts of activity OR achieving 6-8ksteps per day??? (both as part of a comprehensive program

of lifestyle modification)

The role of exercise in weight management

Answer: All of the above!!!

Thomas A. Wadden et al. Circulation. 2012;125:1157-1170

What can exercise do for you?

Improve cardiovascular endurance Increase lean muscle mass Increase resting metabolic rate Reduce waist circumference Reduce risk of co-morbid disease

associated with obesity and mortality Improve emotional state



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What does exercise not do? It does NOT necessarily help patients lose

a lot of weight Either alone or in the context of a larger

weight management plan of care

It helps a little bit with the maintenance ofweight loss and seems to slow the regainof weight for longer periods of time Patients who exercise 300 minutes/wk or

more will maintain weight loss longer thanthose who do less or none at all


Change in body weight for participants in low-fat and low-carbohydrate diet groups after 24 months, based on random-effects linear model.

Thomas A. Wadden et al. Circulation. 2012;125:1157-1170 Copyright © American Heart Association, Inc. All rights reserved.

Percentage reduction in initial weight for overweight or obese women assigned to 1 of 4 exercise prescriptions (in addition to a 1200–1500 kcal/d diet): moderate-intensity/moderate-energy expenditure (expend 1000 kcal/wk), moderate-intensity/high-energy expenditure (expend 2000 kcal/wk), vigorous-intensity/moderate-energy expenditure, or vigorous-intensity/high-energy expenditure.


Copyright © American Heart Association, Inc. All rights reserved.

Percentage weight loss by minutes of physical activity (kilocalories per week) (n=170).


Copyright © American Heart Association, Inc. All rights reserved.

So what’s the bottom line?

Lifestyle Modification can in fact work Can produce a 7-10% reduction in EBW Correlates to reduction in cardiovascular

and other disease states Including Diabetes Mellitus Type II

Exercise and Nutrition together areessential

Regular follow up with PCP, Weightmanagement program etc is essential.

Medical Weight Management –Plan B? Medical Weight Management is a

program where a patient is followedclosely by a Clinician and/or Dietitian

Exist in many forms but the core is regularfollow up with health care providers anda coordinated health care team

May include exercise physiology,psychology, chefs, personal trainers, etc.


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What makes medical management different? The close follow up has been shown to

produce longer lasting weight loss thannon-medical, clinician directedprograms 15-25% loss of EBW out to 3 years for nearly

20% of participants

Pharmacological therapy….

Wait – weight loss drugs…didn’t a different doctor talk about that?

“…a quack who serves viewers horse [expletive

deleted] dressed up as Medicine….” “The

admittedly handsome ringmaster of a middling

mid-afternoon televised snake oil dispensary..”-John Oliver, Last Week Tonight

How is medical management ANY better than the stuff Dr. Oz is pushing?

Admittedly – some issues here Many of the meds are off label Many of the medications do have significant side-

effects No clinician can claim that they’re homeopathic

or natural or supplements Two of them are tightly regulated by the Drug

Enforcement Agency One of them was initially implicated in a major

pharmaceutical scandal that led to numerouscases of failing heart valves and death

They’re expensive in many cases As far as we know the duration of administration is

life long Redinger, Richard N. "Fat storage and the biology of energy expenditure." Translational Research 154.2 (2009):52-

Remember this slide?

Mechanism of various medications used for weight loss

Reproduced without permission from Vesely, J. Obesity, Power Point presentation, October 2014

So what does that prove? Many of the medications that are invoked for

medical weight management, come from atleast some understanding of where they actin the CNS or Gut to exert their influence

Medications – unlike the *ahem* supplementsthat Dr. Oz and others market – are rigorouslyvetted and regulated by the FDA and byadverse reaction data base

That said – caveat emptor – “buyer beware”.All clinicians need to do their due diligenceon pharmaceutical and supplements


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When to use them?

BMI greater than 30 kg/m2

BMI greater than 27 kg/m2 with a significant obesity-related co-morbidity Diabetes, OSA, etc

Patient has reached weight wall Patient reports significant “chatter” or

“inappropriate cravings” or hunger that is not mindful

What are my options? Phentermine – 15 mg, 30 mg, 37.5 mg Topiramate – 25 mg, 50 mg Qsymia (Phentermine/Topiramate) Lorcaserin (Belviq) Wellbutrin Metformin – 500 mg, 1000 mg Liraglutide (Victoza) – SQ injection route Orlistat (Xenical or Alli)

If you really don’t like your patients at all

Contrave (buproprion/naltrexone)

phentermine vs Qsymia Phentermine:

short-acting (8-12 hours) lowest dose available is 15mg capsules. (37.5mg

tablets also available, which can be quartered) cheap ($30-$40 out-of-pocket) Tachycardia, hypertension, hypervigilance (first

few days and with dose changes) Qsymia:

long-acting (24 hours) lowest dose of phentermine is 3.75mg poorly covered, and EXPENSIVE ($340/month) Sustained release, lower side-effect profile

Topamax or Topiramate Strengths – 25 mg, 50 mg Dosing – Can start 25 mg orally daily or

twice daily. May titrate for effect up to a dose of 100 mg orally daily

Side-effects – foggy mentation, can lower seizure threshold

Contraindicated – renal stones, Should check pregnancy test – can

cause cleft palate, other congenital anomalies

lorcaserin (Belviq)

Similar to fenfluramine, except selective 5-HT2C agonist

So far, no evidence that there are any cardiac side effects

Not studied in patients with depression, don’t take with SSRIs (too much serotonin!)

European Medicines Agency – pulled the drug due to safety concerns – cardiac valve issues mainly

bupropion/naltrexone (Contrave) Contrave dosing: 8mg naltrexone plus 90mg

bupropion, two tabs, twice daily (total daily dose is 32mg naltrexone and 360mg bupropion)

Due to cost, I use bupropion XL 150mg QAM plus naltrexone (ReVia) 50mg QAM. Increase bupropion XL to 300mg at first plateau.

Routine side-effects – headache, nausea, some emesis, insomnia, xerostomia

Severe Side-effects – Seizure, Opiate Withdrawal, opiate overdose (to counteract the naltrexone component), allergic rxn(severe), liver failure and hepatitis, mania, angle closure glaucoma, hypoglycemia


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GLP-1 Agonists

liraglutide (Victoza) – once daily Pens for diabetes: 0.6-1.8mg Pens for weight loss: 3mg (not yet available)

exenatide (Byetta) – twice daily exenatide (Bydureon) – once weekly

Side-effects: thyroid tumor,hypoglycemia, renal failure,

Vyvanse Stimulant – cousins are methylphenidate,

amphetamines Indicated for ADHD, Binge Eating

Disorder – off label use for obesity asextension of the Jan 2015 decision by theFDA to extend usage for BED

Side-effects analogous to otherstimulants Dry mouth, insomnia, anorexia, tachycardia,

constipation, jitters, anxiety

Rule of thumb? Start low and titrate for effect With Phentermine ensure the patient has no

underlying coronary conditions – includingany sort of dysrhythmia. Check EKG – look for evidence of PR interval

prolongation, QT interval changes – Controlled substance by DEA (requires paper Rx)

Titrate Topamax slowly Victoza requires teaching to use the injector Educate, educate, educate – self and

patients

So medications, lifestyle, physician/dietitian guided weight management, what if they don’t work???

Recall that even under the bestcircumstances we could only expect 15-25% loss of excess body weight Also recall that this is a bell shaped curve –

some do better, some not as well

What’s left? Endoscopic Procedures/Other Procedures Bariatric Surgery

Endoscopy – into the mouth, past the gums, look out stomach here it comes….

Very very very new and in many casesstill experimental

Can be used to revise challenging/failinggastric bypass (stricture OR need forreduction in pouch size)

Endoscopic Options… Endobarrier

Synthetic bypass – still require laparoscopicprocedure to place

Satisphere/Transpyloric Shuttle (TPS) Delays gastric emptying, induces early satiety Series of inflated or a

single (TPS) balloons,in the distal stomachand duodenum


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Endoscopic Options… cont. ReShape – Intragastric Balloon

450-700cc balloon that fills the stomach,reducing satiety

Allurion – swallowed balloon –self-emptying, passing naturally, can bereplaced every 3 mos

Aspire – diverts ingested nutrients, out ofthe body

Bariatric Surgery…the last best hope

Three primary options

Two widely used

One on the way out Roux-en-Y Gastric Bypass (The Bypass) Vertical Sleeve Gastrectomy (The Sleeve) Laparoscopic Adjustable Gastric Banding

(The Lap Band or Band)

Bariatric Surgery….a weight loss journey

15 miles up20 miles downrange120 seconds

Last best hope perhaps – but not sans risk Major abdominal surgery with all

attendant risks Bleeding Infection Death (0.2%-0.3% nationally) Anesthetic Complications

Obesity Hypoventilation Syndrome

Requires preparation Preoperative clearance for Bariatric

Surgery requires more than just a PCPevaluation. Nurse Clinician – for patient education and

training Clinician – to determine medical stability for

surgery This is not a substitute for a PCP driven pre-

operative exam

Physical Therapist or Exercise Physiologist Dietitian

(continued)

Requires preparation…cont. Psychologist

Numerous psychological risks to BariatricSurgeryAddiction transferrance,

suicide/worsening depression andanxiety, relationship strife, increaseddrug/alcoholism rates

Bariatric Surgeon Needs to be a serious review process to

determine suitability for surgery


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Requires preparation Laboratory studies

CBC, CMP (or BMP + LFT) Hgb A1c Helicobacter pylori IgG aby Cholesterol profile Ferritin, Iron, Iron Saturation, TIBC PTH and TSH Vitamins B1, B6, B12, D, Folate Zinc

EKG Stress Echocardiogram Right Upper Quadrant Ultrasound

Why – it’s just Bariatric Surgery?

The greatest complication/risk ofbariatric surgery is not death, morbidity,vitamin deficiency, internal herniae,ulcers, etc.

The greatest risk, at a rate of 20-30%nationally, is…..

FAILURE

How can failure not be an option if I don’t know what it is??? Broadest terms – failure is defined as an

inability to lose the anticipated amount ofweight OR a significant regain of morethan 80% of excess weight within the firstfew years post-operatively

Here’s the problem Even the Bariatricians and Bariatric Surgeons

don’t have a clear idea of what bariatricsurgery failure looks like

What’s going on??

Changing the anatomy that producesreduction in capacity to absorb ingestedcalories AND reduces capacity totolerate significant volume of food intake

Also changes physiology significantly insuch a way that the brain’s defensive setpoint for weight is reset at a lower level.

The changes of Bariatric Surgery.. Laparoscopic Adjustable Gastric Banding Places an inflatable band around the

proximal stomach The band can be inflated or deflated by

the injection of saline into a port that ispercutaneous

Goal is to achieve a green zone ofconstriction and avoid eitherhyperconstriction or hypoconstriction Too much – nothing gets past, patient

nauseated, emesis Too little – everything gets through – no

weight loss occurs


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Laparoscopic Adjustable Gastric Banding…cont.

Very difficult to maintain, labor intensive,requires regular clinic visits

Weight loss is not as pronouncedbecause there is minimal effect if any onthe underlying physiology that governsobesity.

Laparoscopic Adjustable Gastric Banding


Roux en Y Bypass versus Vertical Sleeve

Both procedures have risen to dominancein the realm of Bariatric Surgery

Vertical Sleeve Gastrectomy dominatesconstituting ~ 80% of the procedures doneat Park Nicollet. This is similar to the national experience

RNY Gastric Bypass constitutes theremaining 20%

Why? Side effect profile Patient understanding Revisable? (?whether this is truly THAT effective)

Creates a restrictiveand diversion state

Creates very smallgastric pouch

Connects pouch tosmall intestine

Duodenum re-connects to the smallbowel hooked tostomach


Roux-en Y Gastric Bypass

Roux-en Y Gastric Bypass…cont. Can produce 70-80% loss of EBW (PNHS

Experience) Not without complications Must be used with a corresponding

program of diet and nutrition Has problems –

Malabsorption, Dumping Syndrome, sutureline leak, vitamin deficiencies, difficultieswith absorption of medication

Can have anastomotic ulcers, internalhernia as long term problems

Roux-en Y Gastric Bypass Why does it work as well as it does?

Has significant effect on the physiology andmany of the signaling molecules involved

Restriction + Malabsorption + Physiology= Weight loss



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Roux-en Y Gastric Bypass…cont. Dumping Syndrome – blessing or curse?

If one eats sweets, fats, both or simply toomuch

Develops weapons grade gastroenteritissymptoms

Lasts 2-6 hours, self-limited, preventable Blessing? May actually serve as barrier to

patient’s eating sweets, fatty foods


Becoming the dominantprocedure

No malabsorption Removes significant

portion of the stomach Produces 65-80% (based

on Park Nicolletexperience) loss of EBW


Vertical Sleeve Gastrectomy

Does have it’s challenges Can’t use in patients with severe GERD,

distal esophagitis, Barrett’s Esophagus Can’t use with previous surgical banding

procedures (Vertical Band Gastrectomy,etc)

Can’t use with previous Nissenfundoplication surgery

Has a 1% risk of suture line leak within the firstfew weeks post-operatively

Vertical Sleeve Gastrectomy…cont. Vertical Sleeve Gastrectomy Why does it work? Limits the physical volume of calories that

can be ingested (much like the LapAdjustable Gastric Band)

Exerts power effect on the physiology aswell

Like RNY Bypass,changes the natureof the conversationbetween brain, gut,and adipose cells


So aside from weight loss…what good is it?? Improves mood and self-esteem Reduces cardiovascular comorbidities

Risk of Heart attack, stroke, hypertension,hyperlipidemia

Reduces risk of Diabetes Mellitus Type II Reduces dependence on medication Can induce remission in the case of RNY

Gastric Bypass with reversal of insulinresistance (can also happen in VerticalSleeve, much less though)

So aside from weight loss…what good is it?? …cont. Reverses fatty liver (Non-alcoholic

steatohepatitis or NASH) Improves level of activity

Reduces stress on load bearing joints (knees,hips, ankles, lumbar spine)

Improves patients body imageperceptions


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What Bariatric Surgery does NOT do… Does not erase your memory of food

preferences Does not act as an easy button Does not last forever

What? The physiological changes of weight loss

surgery can happen once. If the surgery is unsuccessful, if it fails, if

regain happens – square one.

After Surgery: Dietary requirements

Stage 1: Clear liquid diet Day 0-3 post-operativelyStage 2: Full liquid diet Day 4-14 post-operativelyStage 3: Puree diet Day 15-35 post-operativelyStage 4: General diet Day 36 and beyond

No fluids 30 minutes before, during and 30minutes after meals

No carbonated beverages Minimal Alcohol if any for the first 12-18

months High protein, low carb diet Minimize snacking

After Surgery

Physical activity 150 min – 210 min of moderate intensity

physical activity per week

Food journal

Activity journal

Psychological after care if needed

Way way after surgery

Improved activity levels

Improved health Reduced prevalence or risk of many co-

morbid diseases related to obesity

Opportunity for cosmetic surgery at 18-24months Need to ensure weight loss has plateaued

Cosmetic Surgery

Two options Traditional Plastic Surgery Aesthetic Medicine

Goals of cosmetic surgery Remove useless, problematic, flaps of skin

with depleted adipose cells in them. Panniculectomy, Abdominoplasty with Tram

Flap, Thoracoplasty Removed tissue looks like this…..

Cosmetic Surgery after Bariatric Surgery

Michelle Collins Joy “is that a doctor’s Stethoscope” Behar


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But seriously….. Tips to cosmetic surgery post-bariatric

surgery Find a surgeon who is both skilled and willing

to work with bariatric population Monitor intertrigo for signs of erythema,

edema, skin breakdown, etc Why? May be able to get covered by insurance if

skin and tissue damage can be proven

Ensure that weight loss has trulyplateaued

Approach in sensitive way

Why do people fail? Rarely, rarely – failure is because of a

failure of the surgical procedure Pouch distension or inadequate constriction

of the pouch Roux limb not inserted distally enough

Surgery doesn’t erase your memories –not resetting preferences on yoursmartphone

The post-operative regimen is very difficult People sabotaged by success Myth that Bariatric Surgery is forever

Fat Shaming

Fat Shaming

Why the big deal about fat shaming? Fine line between the “fear of God” speech

or “tough love” and fat shaming. True challenge for Clinicians

How do you motivate patients to change weightand behaviors in a supportive, positive way

Use positive language, be supportive,empathize

Obesity usually has a root that is notnecessarily genetics, laziness, or othernegative attributes – may have a deeppsychological root that shaming won’t fix.

Be the safe place for the patient to come

What else can we do to reduce risk of shaming Read the patient Offer chance for patient to be weighed

but NOT reveal the weight It is OK to not know

Avoid phraseology that could becondescending Oh you’re fine or you look marvelous

Do what you all do very well – becompassionate advocates for yourpatient…..


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Unless you’re them……

Michelle Collins Joy “is that a doctor’s Stethoscope” Behar

Thank you so much for your time and attention

Any questions??

2015 WNA Northwoods Clinical Practice Update

Session 2: Fighting Obesity – A Multidisciplinary Approach

Redinger, Richard N. “Fat Storage and the biology of energy expenditure” Translational Research 164.2 (2009) 52‐60

Where are we going today? - Wisconsin Nurses Association€¦ · · 2016-02-03body fat has...

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