OBESITY AND ADDICTION Oct 15, 2021

The following report is proprietary information and constitutes trade secrets of The MetroHealth System and may not be disclosed in whole or part to any external parties without the express consent of The MetroHealthSystem. This document is intended to be used internally for The MetroHealth System discussion.

OBESITY AND ADDICTIONOct 15, 2021

Raman Krimpuri MD MBAAddiction/Obesity Medicine Fellow

MetroHealth Medical Center, Case Western Reserve University

The following planners, speakers, moderators, and/or panelists of the CME activity have no financial relationships with commThe following planners, speakers,

moderators, and/or panelists of the CME activity have no financial relationships with commercial interests to disclose:

Raman Krimpuri, M.D.

ercial interests to disclose:

Raman Krimpuri, M.D.

The following planners, speakers, moderators, and/or panelists of the CME activity have no financial relationships

with commercial interests to disclose:

Raman Krimpuri, M.D.

Acknowledgements

Dr Antenucci and Dr Gupta

I am wholeheartedly thankful to my Mentors:Dr Ewald Horwath

Dr Eileen SeeholzerDr James Yokley

and Dr Sergio Bardaro

Objectives

Obesity Impact and Prevalence

Biological Aspects of Obesity

Psychiatric and Psychological Aspects of Obesity (Addiction)

Treatment of Obesity

What is Obesity?

Ref: Clinical Guidelines on the Identification, Evaluation and Treatment of overweight and Obesity in Adults, NIH – NHLBI 1998

Slide courtesy Eileen Seeholzer

Morbid Obesity

Obesity Impact & Prevalence

Ref: (Obesity in OECD countries - OECD report, 2017)

International Obesity Prevalence

National Obesity Prevalence

Minority Obesity Prevalence

BIOLOGICAL ASPECTS

OF OBESITY

Copyright Pittsburgh partnership

Physiology of Appetite

and Satiation

Regulation of Eating Behaviors: A Biopsychosocial Problem

Psychiatric and Psychological

Aspects of Obesity

Potential Causes OfObesity

The Mental Disorder Itself

Medications Used To Treat

Sedentary Lifestyle

Poor Nutrition/Overeating

Smoking And Substance Abuse

Irregular And Inadequate Sleep

Lack Of Access To Adequate Medical Care

Lack Of Access To Nutrition And Exercise Programs

Obesity and Substance Use Disorder

• Significant associations between BMI and illicit drug use have not been found

• An inverse relationship between current substance use disorders and obesity

• Petry and Colleagues

• Higher rates of lifetime alcohol use disorder among overweight, obese and morbidly obese

• Not found among women

Obesity and Addiction

Obesity and Addiction

• Wang and colleagues

• Used PET imaging • Compared dopamine D2 receptors

concentration

• Conclusion• Obese individuals had fewer D2

receptors

Treatment of Obesity

The Ultimate Goal

ImprovedMetabolic

HealthNutrition

Recommendations/Plan

Activity Recommendations/Plan

Behavioral Therapy (helps

with the “how-to)Medications

Bariatric Surgery

Lifelong monitoring and follow-up

Intensive Lifestyle Intervention

Intensive Lifestyle Intervention

• High-intensity programs, minimum >16 visits over 6 months

• Focus on strategies to achieve 500–750 kcal/day energy deficit

• Individualized diet

Beyond 1 year, start weight maintenance

program

• Monthly contact• Body weight

monitoring• Other self-monitoring• Physical activity (200-

300 min/week)

American Diabetes Association. Diabetes Care 2019 Jan; 42(Supplement 1): S81-S89.https://doi.org/10.2337/dc19-S008

STRIDES (Metro)

Illustration by JR Bee, Verywell

Behavioral Therapy: The how to

Current Medications For Weight

Loss

Appetite suppressant: GLP-1 agonist: Liraglutide , Semaglutide (injectables)

Appetite suppressant: Phentermine, Topiramate

Appetite and craving suppressant: Buproprion-Naltrexone

Lipase Inhibitor: Orlistat

Appetite suppressant: Metformin

• Adjunctive to lifestyle modifications

• Recommended as treatment for patients with

• BMI >40

• BMI 35-39.9 if unable to achieve durable weight loss and comorbidity improvement with nonsurgical efforts

• May be considered for BMI 30-34.9 with Type 2 Diabetes

American Diabetes Association. Diabetes Care 2019 Jan; 42(Supplement 1): S81-S89.https://doi.org/10.2337/dc19-S008

What is the Role of Surgery?

Puzziferri N, Almandoz JP. Sleeve Gastrectomy for Weight Loss. JAMA. 2018;319(3):316. doi:10.1001/jama.2017.18519

Kashyap SR, Gatmaitan P, Brethauer S, Schauer P. Bariatric surgery for type 2 diabetes: weighing the impact for obese patients. Cleve Clin J Med. 2010;77(7):468–476. doi:10.3949/ccjm.77a.09135

Puzziferri N, Almandoz JP. Sleeve Gastrectomy for Weight Loss. JAMA. 2018;319(3):316. doi:10.1001/jama.2017.18519

Kashyap SR, Gatmaitan P, Brethauer S, Schauer P. Bariatric surgery for type 2 diabetes: weighing the impact for obese patients. Cleve Clin J Med. 2010;77(7):468–476. doi:10.3949/ccjm.77a.09135

Psychiatric Clearance for Bariatric Surgery: Is the Best Predictor of Future Behavior Really Past Behavior?

• A study of 218 patients who received psychological evaluation and bariatric surgery at MetroHealth were followed up at 1 year.

• All patients had a mean 28% reduction in BMI (63.3% excess weight loss and 29.1% total weight loss) at 1 year postoperatively.

• Conclusion: Findings indicate that preoperative weight loss should not be considered in isolation when clearance for bariatric surgery is being evaluated.

Source: Krimpuri, Yokley, Seeholzer, Horwath, Thomas & Bardaro.Surgery for Obesity and Related Diseases 14 (2018) 60–65.

Following Bariatric Surgery

Following Bariatric Surgery

Following Bariatric Surgery

Following Bariatric Surgery

Krabseth HM, Strømmen M, Spigset O, Helland A. Effect of Sleeve Gastrectomy on Buprenorphine Pharmacokinetics: A Planned Case Observation. Clin Ther. 2020 Nov;42(11):2232-2237. doi: 10.1016/j.clinthera.2020.08.016. Epub 2020 Sep 25. PMID: 32981745.

Take Away Points

1. Inquire about Bariatric surgery2. Monitor weight and metabolic markers3. If 5 % weight gain: Refer to Nutrition and Weight

Management4. Important to assess for and monitor psychiatric

disorders and substance use after bariatric surgery long term

5. Early and consistent integrated care helps to identify patients who require higher levels of care or service, potentially avoiding adverse outcomes

References• Heneghan, H. M., Heinberg, L., Windover, A., Rogula, T., Schauer, P. R. (2011). Weighing the evidence for an association between obesity and

suicide risk. Surg Obes Rel Dis, 8(1), doi: 10.1016/j.soard.2011.10.007

• Centers for Disease Control and Protection (2021, March 3). Defining Adult Obesity. Overweight & Obesity, Centers for Disease Control and Prevention. https://www.cdc.gov/obesity/data/prevalence-maps.html

• Centers for Disease Control and Protection (2021, March 31). Adult obesity maps. Overweight & Obesity, Centers for Disease Control and Prevention. https://www.cdc.gov/obesity/data/prevalence-maps.html

• Every-Palmer, S., Romans, S. E., Stubbs, R., Tomlinson, A., Gandhi, S., Huthwaite, M. (2020). Experiences of weight-loss surgery in people with serious mental illness: A qualitative study. Front Psychiatry, 11. doi: 10.3389/fpsyt.2020.00419

• Cunningham, J. L., Merrell, C. C., Sarr, M., Somers, K. J., McAlpine, D., Reese, M., Stevens, S. R., Clark, M. M. (2012). Investigation of antidepressant medication usage after bariatric surgery. Obesity Surgery, 22(4), 530-535. doi: 10.1007/s11695-011-0517-8.

• Arroyo-Johnson, C., Mincey, K. D. (2016). Obesity epidemiology worldwide. Gastroenterology Clinics of North America, 25(4), 571-579, from https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S0889855316300693?returnurl=https:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS0889855316300693%3Fshowall%3Dtrue&referrer=https:%2F%2Fpubmed.ncbi.nlm.nih.gov%2F27837773%2F

• ASMBS (2016, June). Recommendations for the presurgical psychosocial evaluation of bariatric surgery patients. https://asmbs.org/resources/recommendations-for-the-presurgical-psychosocial-evaluation-of-bariatric-surgery-patients

• ASMBS (2021). Who is a candidate for bariatric surgery?. Treat your obesity: Public learning center. https://asmbs.org/patients/who-is-a-candidate-for-bariatric-surgery

• ASMBS Public Education Committee (2020, September). FAQ’s of bariatric surgery. Treat your obesity: Public learning center. https://asmbs.org/patients/faqs-of-bariatric-surgery

• ASMBS Public Education Committee (2020, September). Benefits of Weight Loss Surgery. Treat your obesity: Public learning center. https://asmbs.org/patients/benefits-of-weight-loss-surgery

• ASMBS Public Education Committee (2021, February). Life after

• Sarwer, D. B., Heinberg, L. J. (2020). A review of the psychosocial aspects of clinically severe obesity and bariatric surgery. American Psychologist, 75(2), 252-264. doi: 10.1037/amp0000550

• Puhl, R. M., Heuer, C. (2009). The stigma of obesity: A review and update. Obesity, 17(5), 941-964. doi: 10.1038/oby.2008.636.

• World Health Organization (2020, April 1). Obesity. Department of Nutrition and Food Safety (NFS). https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight

• Peet, M. (2004). Sugar associated with Schizophrenia and Depression British Journal of Psychiatry, 184, 484-495

• Schwartz, M., Woods, S., Porte, D. et al. Central nervous system control of food intake. Nature 404, 661–671 (2000). https://doi.org/10.1038/35007534

• Krabseth HM, Strømmen M, Spigset O, Helland A. Effect of Sleeve Gastrectomy on Buprenorphine Pharmacokinetics: A Planned Case Observation. Clin Ther. 2020 Nov;42(11):2232-2237. doi: 10.1016/j.clinthera.2020.08.016. Epub 2020 Sep 25. PMID: 32981745.

Rkirmpuri@metrohealth.org

Mardi Gras World: New Orleans33rd Annual Meeting of The Obesity Week

Questions

• We encourage the use of person-first language

• “adults with obesity” and not “obese adults”