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Tackling the Obesity EpidemicTNP Spring 2020

Susan Bowlin, MSN, APRN, FNP-BC, ACNP-BC, CBN

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Disclosures

o None

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Objectives

1. Discuss the diagnosis and underlying

pathophysiology involved in the disease of

obesity.

2. Discuss utilization of current treatment

guidelines for obesity with emphasis on

pharmacologic options.

3. Understand essential nutrition and

behavior modifications involved in making

lifelong changes to help sustain weight

loss.

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THE DISEASE OF OBESITY

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2 Years After Sleeve: Notice the JOY!

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Impact on Mortalityu Obesity is associated with a 50-100% risk of

premature death compared to healthy weight individuals.

u Median survival rate is reduced by two-four years for individuals with BMI 30-35

u Median survival rate is reduced by eight-to-ten years for individuals with BMI 40-45 which is comparable to smoking.

Office of the Surgeon General – U.S. Department of Health and Human Services. Overweight and obesity: health consequences. Accessed March 2012 from http://www.surgeongeneral.gov/topics/obesity/calltoaction/fact_consequences.html

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A look back in time…u In 2000 starting to see the

increasing prevalence of obesity.

u BMI seen as a major risk factor for DM.

u Low rates of addressing BMI with patients.

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Evolving definition of obesity

u Obesity is a chronic disease

u NOT a character flaw

u Excess weight or unhealthy weight

u It has been proposed to call obesityu Adiposity-based chronic disease (ABCD)

Obesity Algorithm®. ©2020 Obesity Medicine Association.

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Definition of Obesity

“Obesity is defined as a chronic, relapsing, multi-factorial, neurobehavioral disease, wherein an increase in body fat promotes

adipose tissue dysfunction and abnormal fat mass physical forces, resulting in adverse

metabolic, biomechanical, and psychosocial health consequences.”

Obesity Algorithm®. ©2020 Obesity Medicine Association.

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National Obesity TrendsNational Health and Nutrition Examination Survey (NHANES), 2011-2014 data

GENDER AGE ETHNICITY

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Texas Obesity Rates: 33.7% Ranking 8th/51

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5

10

15

20

25

30

Obe

sity

Rat

e

Gender

Obesity Rate by Gender (2012)

Men Women

28.5

0

5

10

15

20

25

30

35

40

45

Obe

sity

Rat

e

Race

Obesity Rate by Race (2016)

White Black Latino

0

5

10

15

20

25

30

35

40

Obe

sity

Rat

e

Age

Obesity Rate by Age Group (2016)

18 -25 26-44 45-64 65+

30.0%

29.2%

42.4% 37.4

%

23.9%

34.2%

38.9%

30.0%

https://stateofobesity.org/states/tx

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Effects of BMI and Smoking Status on Survival

Men 35-100 years old

N Engl J Med 2010; 362:855-857

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Cost of Obesity

u Cost of obesity in the United States in 2000 was more than $117 billion

u Many insurance companies do not cover clinical or non-clinical weight-loss programs

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Is This Our Future… Obesity of Tomorrow?

Prevalence of Obesity Among U.S. Adults Ages 20-74

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10

23

3546

57

0

20

40

60

80

100

30-34.9 35-39.9 40-44.9 45–49.9 ≥50

Ob

esi

ty d

iagn

osi

s, %

BMI

Proportion of Actual Diagnoses of Obesity by BMI

Yet, Obesity Remains Underdiagnosed in the U.S.

Crawford AG et al. Popul Health Manag. 2010;13:151–161. Data from the GE Centricity System/EMR data of 6 millions records in the US

<23% of individuals with a BMI between 35-40 kg/m2 are diagnosed with obesity

43% of patients with BMI ≥50 kg/m2 are not diagnosed

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u Potential impact of 5% average BMI reduction in the

U.S. by 2020:

u3.5 million cases hypertension avoidedu0.3 million cases cancer avoided

u2.9 million cases heart disease and stroke avoided

u3.6 million cases diabetes avoided

u1.9 million cases arthritis avoided

The Good News? Modest Weight Loss Can Reduce Disease Risk

Levi et al. F as in fat: how obesity threatens America’s future, 2012. Available at: http://healthyamericans.org/assets/files/TFAH2012FasInFatFnlRv.pdf

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Obesity Care Gap

If treating obesity reduces the risk of so many health conditions and healthcare

costs, why do so few healthcare providers diagnose and treat obesity?

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Few People with Obesity are Treated in the U.S.

Sources: CDC 2014 (adults is defined as >20yrs. American Heart Association. Statistical Fact Sheet 2013 Update: Overweight and Obesity. http://www.heart.org/idc/groups/heart-public/@wcm/@sop/@smd/documents/downloadable/ucm_319588.pdf. Accessed June 9, 2014. Understanding the Treatment Dynamics of the Obesity Market, IMS Database (NPA) Aug 31, 2014; ASMBS website, estimated number of bariatric surgeries, published July 2016; asmbs.org

~80 million adults with obesity in

the U.S.

<1% receive a prescription for an anti-obesity medication in a

given month

~195,000 people per year receive bariatric

surgery

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Influences of Our Times

Patient

Portions

Family Schedule

Work Schedule

Business Meals

Eating Out

Distractions

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CAN YOU RELATE?

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Convenience Crisis

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Convenient Abundance

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Adiposopathy Stress Cycle

Obesity Algorithm®. ©2020 Obesity Medicine Association.

Obesity, Adiposopathy, and Metabolic Disease

Chronic StressBehavior Changes, Endocrinopathies, and Immunopathies

Increasing Body Fat Worsening Adipose Tissue Function

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Classifications

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BMI kg/m2 Classification

18.5-24.9 Heathy

25-29.9 Overweight/Pre-obese

≥ 30 Obese

30.0-34.9 Class I Obesity

35-39.9 Class II Obesity

≥ 40 Class III Obesity

Waist CircumferenceHealth Risk

Women Men

Low Risk < 31.5 inches < 37 inches

Moderate Risk 34.5-35 inches 37-40 inches

High Risk 35 inches or more > 40

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Height (ft/in)

4’9” 4’11” 5’1” 5’3” 5’5” 5’7” 5’9” 5’11” 6’1” 6’3”

154 33 31 29 27 26 24 23 22 20 19

165 36 33 31 29 28 26 24 23 22 21

176 38 36 33 31 29 28 26 25 23 22

187 40 38 35 33 31 29 28 26 25 24

198 43 40 37 35 33 31 29 28 26 25

209 45 42 40 37 35 33 31 29 28 26

220 48 44 42 39 37 35 33 31 29 28

231 50 47 44 41 39 36 34 32 31 29

243 52 49 46 43 40 38 36 34 32 30

254 55 51 48 45 42 40 38 35 34 32

265 57 53 50 47 44 42 39 37 35 33

276 59 56 52 49 46 43 41 39 37 35

287 62 58 54 51 48 45 42 40 38 36

298 64 60 56 53 50 47 44 42 39 37

309 67 62 58 55 51 48 46 43 41 39

320 69 64 60 57 53 50 47 45 42 40

HEIGHTHT

WEIGHT

Body Mass Index (BMI)

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BMI: a universal measurementbut certainly not perfect

• Easily reproducible and consistent

• Low cost

• Commonly used

• Problems:

u Does not account for muscle mass

u Does not distinguish between gender, ethnic or racial considerations

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2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults, Volume: 129, Issue: 25_suppl_2, Pages: S102-S138, DOI: (10.1161/01.cir.0000437739.71477.ee)

ACC/AHA Obesity Guideline 2013

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Nutritional Intervention

Physical Activity

Pharmaco-therapy

Bariatric Procedures

Behavior Therapy

Motivational Interviewing

Management Decisions

Evaluation and Assessment

Obesity Algorithm

Obesity as a Disease

Data Collection

Obesity Algorithm®. ©2020 Obesity Medicine Association.

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Obesity Comorbidities…actually…complications

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Comorbidities of Obesity

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Common manifestations reported by patients

Insomnia/fatigue/daytime sleepiness

Mood changes/forgetfulness/depression

Lack of interest in socializing & sexual activity

GERD

Pain: back, knee, hip, foot

Stress Incontinence

Headache

Peripheral swelling

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Physical Exam Findings

Increased neck circumference

Modified mallampati score of 3 or 4

Tonsillar hypertrophy/enlarged uvula

Peripheral edema

Cardiac dysrhythmia

HTN

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Healthy Nutrition for Obesity

• Limit processed foods

• Limit empty calories such as sweets, candy, chips

• Beware of beverages with high calories/sugar

• Encourage healthy proteins and fats

• Carbohydrates should be complex carbs over simple carbs and look for low glycemic index foods

• High fiber foods

• Read the labels not the advertising!

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Factors that affect nutrition

• Individual food preferences, eating behaviors, meal plans and schedules

• Cultural background & traditions

• Availability of food

• Financial constraints

• Nutritional knowledge

• Cooking skills and interest

• Household makeup: cooking for 1?

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Popular diets

Ketogenics Paleo Atkins Mediterranean

OrnishDASH (Dietary

Approaches to Stop HTN)

Commercial Diet programs• Weight Watcher’s• Nutrisystem

• Jenny Craig

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Hunger, appetite and satiety

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Tools/Questionnaires'

STOP-Bang Questionnaire

Screen for sleep apnea

QOL Indicator

2018 PAR-Q+ to establish exercise readiness

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Sleep Apnea

u In-office questionnaire

u Sleep study referralu In-home study

u In-lab overnight study

u AHI (Apnea hypopnea index)

u 5-15/hour = mild sleep apnea

u 15-30/hour = moderate sleep apnea

u > 30/hour = severe sleep apnea

u Consequences of untreated OSA

u Worsening obesity

u CHF

u AF

u Nocturnal dysrhythmias

u CVA

u HTN

u DM

u Pulmonary HTN

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Gender Specific Manifestations of Adiposopathyu Women

u Hyperandrogenemia

u Hirsutism

u Acne

u Polycystic ovarian syndrome

u Menstrual disorders

u Infertility

u Gestational DM

u Preeclampsia

u Thrombosis

u Men

u Hypoandrogenemia

u Hyperestorogenemia

u Erectile dysfunction

u Low sperm count

u Infertility

Obesity Algorithm®. ©2020 Obesity Medicine Association.

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Increased risk of cancer

• Bladder cancer

• Brain cancer

• Breast cancer (post-menopausal)

• Cervical cancer

• Colon cancer

• Endometiral/uterine

• Kidney cancer

• Leukemia

• Liver cancer

• Multiple myeloma

• Non-Hodgkin lymphoma

• Pancreatic cancer

• Prostate cancer (worsened prognosis, not necessarily increased risk)

• Stomach cancer

• Thyroid cancer

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New Patient Diet History

Previous diet history

Highest and lowest adult weights

Co-morbidities

Eating disorders

Activity level: current and previous

Social: tob/ETOH/drugs/employment/support system/home environment

Medications/allergies

Eating out

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Eating Historyu Meals/Snacks

u Timing

u Frequency

u Nutritional content

u Portions

u Who prepares foods

u Behaviors

u Triggers/nighttime eating/binge eating/readiness for change

u Record keeping

u Physical activity

u Enjoyment

u Barriers

u Frequency

u Access

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Lab Workupu Fasting CMP

u Hemoglobin A1C

u Fasting lipids

u Uric Acid

u Thyroid panel

u Vitamin D, B-1, B-12

u CBC

u Iron studies

u Based on H&P the patient may need additional testing such as:

u Cardiac stress test

u Sleep study

u Echo

u Bone density scan

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Physical Activity

Assess readiness

Able to walk?

Weight bearing exercise?

Ultimate goal is at least 150 minutes weekly of moderate physical activity and resistance training for core strength

Consider PT referral

Network with your local trainers and gyms

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MOTIVATIONAL INTERVIEWING

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Pre-contemplationUnawareness of the problem

ContemplationThinking of change in the next 6 months

PreparationMaking plans to change now

ActionImplementation of change

RelapseRestart of unfavorable behavior

Stages of Change

Progress

Obesity Algorithm®. ©2020 Obesity Medicine Association.

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Motivational Interviewing: Focusu Collaboration

• Working together to find and implement pragmatic solutions

• Not focusing on who is right and who is wrong

u Evocation

• Drawing out the patient’s thoughts and ideas regarding solutions

• Not telling the patient what to do

u Autonomy

• Empowering the patient to own the solution

• Not the authoritarian power of the clinician

All or nothing

Obesity Algorithm®. ©2020 Obesity Medicine Association.

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Motivational Interviewing Techniques: 5A’s of Obesity Management

• Ask for permission to discuss body weight.• Explore readiness for change.Ask• Assess BMI, waist circumference, and obesity stage.• Explore drivers and complications of excess weight.Assess• Advise the patient about the health risks of obesity, the benefits of modest weight

loss (i.e., 5-10 percent), the need for long-term strategy, and treatment options.Advise• Agree on realistic weight-loss expectations, targets, behavioral changes, and

specific details of the treatment plan.Agree• Assist in identifying and addressing barriers; provide resources; assist in finding

and consulting with appropriate providers; arrange regular follow up.Arrange/AssistObesity Algorithm®. ©2020 Obesity Medicine Association.

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Multifactorial Approach to Therapy

Increased Physical Activity

Behavioral Therapy

Dietary Changes

• Diet recall• Previous Success• Build on

preferences

• Determine baseline

• Discuss interests• Discuss barriers• Refer as needed

• Primary care• Dietitian• Counselor

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HUNGERHORMONE REGULATION

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Complexities of Appetite Regulation

AGRP: agouti-related peptide; α-MSH: α-melanocyte-stimulating hormone; GHSR: growth hormone secretagogue receptor; INSR: insulin receptor; LepR: leptin receptor; MC4R: melanocortin-4 receptor; NPY: neuropeptide Y; POMC: proopiomelanocortin; PYY: peptide YY; Y1R; neuropeptide Y1 receptor; Y2R: neuropeptide Y2 receptor. Apovian CM, Aronne LJ, Bessesen D et al. J Clin Endocrinol Metab. 2015;100:342-362.

Complexities of Appetite Regulation

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Hunger Hormones

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GLP-1

Cardiovascular effects of Glucagon-like peptide 1 (GLP-1) receptor agonists - Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/Pleitropic-effects-of-GLP-1-or-GLP-1R-agonists-Adapted-from-references-24_fig2_267740019 [accessed 5 Aug, 2018]

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Hunger Hormones

Hormone Source Effect

CCK GI Tract Limits size of meal

Amylin, insulin, glucoagon

Pancreas Limits size of meal

PYY Ileum/colon Postpones need to eat

GLP-1 Stomach Postpones need to eat

Oxcyntomodulin Stomach Postpones need to eat

Leptin Adipose tissue Lon term regulation

Ghrelin Stomach Increase appetite

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Goals of Treatment

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ANTI-OBESITYMEDICATIONS(AOMS)

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Drugs That Increase Weight• TCAs• MOAIs• Paroxetine

• Lithium• Olanzapine• Clozapine• Risperidone

• Carbamazepine• Valproate• Mirtazapine

• Gabapentin• Amitriptyline• Valproic acid

• Diphenhydramine

• Some beta blockers• Propranalol• Atenolol

• Metroprolol• Older calcium channel

blockers• Nifedipine• Amlodipine

• Felodepine• Diabetes medications

• Most insulins• Sulfonylueas

• Thiazolidinediones• Meglitinides

• Some epilepsy medications

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Anti-obesity Medications (AOBMs)Pharmacotherapy

Adipex

Belviq

Qysmia

ContraveSaxenda

FDA pulled off market due to potential increase cancer rates

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Food and Drug Administration (FDA) Principlesu FDA-approved Anti-obesity Medication Indications:

u Patients with obesity (e.g., BMI > 30kg/m2)

u Patients who are overweight (e.g., BMI > 27kg/m2) with presence of increased adiposity complications (e.g., type 2 diabetes mellitus, hypertension, dyslipidemia)*

u Anti-obesity medications are contraindicated in patients hypersensitive to the drugs

*If no clinical improvement (e.g., at least 4 - 5% loss of baseline body weight) after 12-16 weeks with one anti-obesity medication, then consider alternative anti-obesity medication or increasing anti-obesity medication dose (if applicable).

Obesity Algorithm®. ©2020 Obesity Medicine Association.

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Obesity Algorithm®. ©2020 Obesity Medicine Association.

Drug Description Main Side Effects Drug InteractionsPhentermine Phentermine was approved in

1959, and is the oldest available approved anti-obesity drug. It is a DEA Schedule IV stimulant agent approved for short-term use (12 weeks). Some patients may lose about 5% of body weight.

Side effects include headache, high blood pressure, rapid or irregular heart rate, overstimulation, tremor, and insomnia. Should not use with overactive thyroid or uncontrolled high blood pressure or seizure disorder. Contraindicated in patients with history of cardiovascular disease, within 14 days of monoamine oxidase inhibitors, glaucoma, agitated states, drug abuse

Monoamine oxidase inhibitors, sympathomimetics, antidepressants, alcohol, adrenergic neuron blocking drugs, and some anesthetic agents

Orlistat Orlistat impairs digestion of dietary fat. Lower doses are approved over-the-counter. Some patients may lose about 5% of body weight.

Side effects include oily discharge with flatus from the rectum, especially after fatty foods. (May help with constipation.) May promote gallstones and kidney stones. Will need to take a multivitamin daily. Contraindicated in chronic malabsorption syndrome and cholestasis.

Cyclosporine, hormone contraceptives, seizure medications, thyroid hormones, warfarin

Anti-Obesity Drug Summary (All have contraindications for hypersensitivity and pregnancy)

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Obesity Algorithm®. ©2020 Obesity Medicine Association.

Drug Description Main Side Effects Some Drug Interactions

Liraglutide Liraglutide is an injectable drug, that in lower doses (1.8 mg per day), is also used to lower blood sugar. Some patients may lose 5 – 10% of body weight with the higher dose of the liraglutide 3.0 mg per day, which is the dose approved for treatment of obesity.

Adverse reactions include nausea, hypoglycemia, diarrhea, constipation, vomiting, headache, decreased appetite, dyspepsia, fatigue dizziness, abdominal pain, increase lipase, and renal insufficiency. Contraindicated with personal of family history of medullary thyroid cancer or Type 2 Multiple Endocrine Neoplasia syndrome. Discontinue with suspected pancreatitis, gall bladder disease, or suicidal behavior and ideation.

May slow gastric emptying, which may impact absorption of concomitantly administered oral medication.

Naltrexone / bupropion

This is a combination of naltrexone (opioid antagonist used for addictions) and bupropion (used for depression and smoking cessation). Some patients may lose 5 - 10% of body weight.

Naltrexone / bupropion can cause nausea, constipation, diarrhea, and headache. The bupropion component is an antidepressant, and antidepressants can increase the risk of suicide thinking in children, adolescents, and young adults; monitor for suicidal thoughts and behaviors. Should not be used in patients with uncontrolled high blood pressure, seizure disorders, or drug/alcohol withdrawal.

Opioid pain medications, anti-seizure medications, MAO inhibitors, and possible drug interactions with other drugs.

Phentermine / topiramate

This is a combination of phentermine (anti-obesity drug) and topiramate (used to treat seizures and migraine headaches). This DEA Schedule IV drug is approved as a weight management pharmacotherapy. Some patients may lose 5 – 10% of body weight.

Phentermine / topiramate can cause tingling or numb feelings to extremities, abnormal taste, insomnia, constipation, and dry mouth. Should not be used in patients with glaucoma, uncontrolled high blood pressure, heart disease, or hyperthyroidism. Topiramate can cause birth defects. Therefore, phentermine / topiramate should not be started until a pregnancy test is negative, unless the woman is using acceptable contraception, and pregnancy tests should be done monthly during use.

Monoamine oxidase inhibitors. May alter oral contraceptive blood levels.

Anti-Obesity Drug Summary (All have contraindications for hypersensitivity and pregnancy)

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Adipex(Phentermine 8, 15, 30 & 37.5 mg)DEA schedule IV

Advantages• Generic

• Inexpensive

• Good for overeaters

• Decreases cravings

Disadvantages• Not good for meal skippers

• Limited duration: 3 months

• Side effect profile

• Do not use with known ischemic vascular disease or uncontrolled HTN

Dry mouth Tachycardia Insomnia

Common side effects

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Qsymia(Phentermine HCL/Topiramate)DEA schedule IV

Weeks1-2

Weeks3-12+

Completion of the FDA-mandated REMS program is optional and not required prior to prescribing phentermine HCL/topiramate extended release. Implementation of a REMS program by clinicians and pharmacies is intended to provide appropriate safety information to females of reproductive potential.

Weeks 13-14

Weeks 15+

If dose escalation needed for >3% weight loss after 12 weeks

Write 2 prescriptions when initiating therapy

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Qsymia(Phentermine HCL/Topiramate)DEA schedule IV

Mechanism of action Targets pro-opiomelanocortin (POMC) neurons in hypothalamus decreasing appetite & cravings and increases satietySympathomimetic amine, increases GABA activity, carbonic anhydrase inhibitor

Pharmacokinetics Phentermine metabolized by liver & excreted by kidney Topiramate is excreted mainly by kidney

Side Effects Paresthesia, dizziness, change in taste, constipation, dry mouth

Fetal toxicity: cleft palate. Increased HR, may cause DUB but NOT an increased risk of pregnancy; OCP should NOT be discontinued if spotting occurs. Avoid alcohol as may potentiate CNS depressants; may potentiate ↓K+ of non-potassium sparing diuretics. Need to increase hydration, may ↑kidney stones.

Contraindications Pregnancy, glaucoma, MAOIs (within 14 days), hyperthyroidism

Monitoring Obtain negative pregnancy test before staring and monthlyPossible lab abn: ↓ glucose; ↑ creatinine; metabolic acidosis

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Saxenda (Liraglutide)

Mechanism of action

GLP-1 agonist; POMC neuron activation (appetite control via the satiety center)Delays gastric emptying

Pharmcokinetics 98 % protein boundNo specific metabolizing organ (SC injection)5-6 % excreted in urine/feces

Side Effects Nausea, headache, vomiting, diarrhea, constipation, dizziness, dyspepsia, fatigue

Contraindications Personal or family history of medullary thyroid carcinoma (MTC); multiple endocrine neoplasia syndrome type 2 (MEN 2); acute pancreatitis; active gallbladder diseaseRoutine monitoring of serum calcitonin or thyroid ultrasound is of uncertain value.

Caution Possible hypoglycemia with concomitant sulfonylurea, consider lowering dose and check glucose more frequently; renal impairment may worsen usually in association with dehydration associated with N/V/D.Patients on Saxenda should be monitored for emergence or worsening of depression or suicidal thoughts.

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L van Bloemendaal et al. J Endocrinol 2014;221:T1-T16

GLP-1 & Glucose metabolism

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Saxenda (Liraglutide 3 mg)

§ No pregnancy or breastfeeding

§ No personal or family history of

§ Medullary thyroid cancer (MTC)

§ Multiple endocrine syndrome type 2 (MEN 2)

§ Pancreatitis

Week

1

Week

2

Week

3

Week

4

Week

5

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Contrave(Naltrexone 8 mg/Bupropion 90 mg)

Mechanism of action Naltrexone is an opioid antagonistBuproprion is an antidepressant suppresses appetite & craving

Pharmacokinetics Inhibits neuronal uptake of dopamine & norepinephrine; activates POMC neurons in the hypothalamus leading to decreased appetite

Side Effects N&V, constipation, diarrhea, headache, dry mouth, insomnia

Contraindications Should NOT be administered with opiods or with other drugs metabolized by CYP2D6 (SSRIs, MAOIs, antipsychotics (Haldol, risperidone & thioridazine; beta blockers (metoprolol); type 1C antiarrhythmics (propafenone & flecainide)Do not take with uncontrolled HTN or history of seizuresAvoid use in individuals with eating disorders

Black Box Warning Suicidal behavior & ideation

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Contrave(Bupropion 90 mg/Naltrexone 8 mg)

§ Good with depressed, emotional eating

§ No pregnancy, seizures, opioduse or eating disorders

§ Nausea can be a factor, don’t accelerate the dose titration

§ Consider discontinuation if <5% weight loss after 12 weeks

Week1

Week2

Week3

Week4

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Contrave(Bupropion 90 mg/Naltrexone 8 mg)

u D/C 5 days preop

u Restart 7-10 days after pain medications complete: up titrate again

u In general, no need to taper off when stopping Contrave.

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Anti-Obesity PharmacologyDual Benefits

Obesity along with: May consider:

Diabetes Saxenda

Migraines Qysmia

Depression Contrave

Smoking Contrave

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AOM Case Studies

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Jessica: 33 year old female

u Started program in April

u 232 lbs. BMI 39.9u Obesity, depression, fatigue, insomnia

u Initially worked on diet, exercise & behavior modification

u Existing Rx: Buproprion XL 300 mg daily & MVI

u Started Phentermine 15 mg daily in June: 228 lbs.u Discontinued phentermine after 3 months

u Started Saxenda August: 216 lbs.

u F/u q 2-4 weeks: November 200 lbs.

u Reports big improvement of fatigue & depression

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Jessica

u 4/25/19

u CBC & CMP WNL; chol 189, trig 88, HDL 59, LDL 112, A1C 5.2, insulin 11, TSH 4.25

u 4/28/18 EKG WNL

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Barbara64 year old

u Hx/ouBack pain: recently

had stimulator placed

uAsthmauSkin canceruMild

depression/anxiety

u RXuTizanidineuAdzenysuXanax prnuWellbutrinuPregavalinuZolpidem

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Barbara64 yo

u HW 178

u LW in 5 years 150u High school weight 125

u Contributing factor to weight gain: back pain

u She was a gymnast and coach most of her life which resulted in chronic back pain

u When she presented to program BMI was 32 and she was very frustrated after doing a local meal prep program that she didn’t lose weight. Does not enjoy cooking. Often skipping meals

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Barbara64 year old

u Got started in program working with NP and RD on nutritional counseling and behavior modification.

u Recent labs with PCP, including thyroid panel, were WNL; EKG WNL

u Discussed that Prozac may be contributing to weight gain and Wellbutrin may be an alternative to consider with PCP

u Attempted Saxenda, d/c due to side effects.

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Barbara64 year old

Vital Signs

10/10 182 lbs. BMI 32.310/28 176 lbs.

10/30 174 lbs. BMI 30 Started Saxenda but d/c due to side effects

11/11 168 lbs. BMI 29

11/26 165 lbs.12/4 163 lbs. BMI 28

2 months lost 19 lbs. & 10% TWL!

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Sheila (54 year old)54 y

u Depression

u GERD

u Hypothyroidu OSA

u Morbid obesity

u Labs

u CBC WNL

u CMP WNL except elevated AST 39

u Chol 167, trig 99, HDL 59, LDL 88

u Meds:

u Escitalopramu Omeprazole

u Synthroid

u Estradiol

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Sheila (54 year old)

u 4/11/19 157/80 254 lbs. BMI 45

u 5/16/19 124/72 256 lbs. BMI 45

u 6/20/19 138/86 247 lbs. BMI 43

u 7/25/19 239 lbs BMI 42.5

u 8/22/19 131/90 235 lbs. BMI 41.7u 9/24/19 231 lbs. BMI 41.1

u 10/22/19 136/87 230.9 lbs. BMI 40.8

u 12/3/19 136/92 230 lbs. BMI 40.7

u 2/10/20 137/94 234 lbs. BMI 41.4

Started Saxenda

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Mr. & Mrs…

Cassieu 31 year old female

u Referred by Fertility specialist

u BMI 48

u BP 121/93

u Waist circ 46”

Andyu 39 year old male

u Supporting his wife and started program.u OSA

u Fatigue

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Couple’s Joint Effort

Cassie

u Struggled with weight as a child

u HS weight 185 lbs.u Turned to food when parents

divorcedu Most successful diet attempt in

past was 3 years ago, took 1 ½ hr lunch and went to gym

u Met spouse, more relaxed routine and increased stress at work with frequent meetings during lunch.

Andy

u 39 year old male

u Supporting his wife and started program.u OSA

u Fatigue

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Husband & wifeCourntey

u Labs

u Chol 207u Trig 148

u HDL 53

u LDL 124

u Vit D 13.6

u Insulin 27.1

u CMP, CBC, TSH B 12 WNL

u EKG WNL

Andrewu Labs:

u Glucose 127

u A1C 6.3

u Insulin 74

u AST 49 & ALT 112

u Chol 220

u Trig 211

u HDL 32u LDL 145

u Vit D 9.7

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Joint Efforts

Cassieu Other Medications

u Claritin-D

u Prenatal vitamin

u Started

u Qsymia

u 3.75mg/23mg QD x 2 weeks

u 7.5 mg/46 mg QD

u Metformin ER 500 mg QD

u Vit D 50,000 IU weekly

Andy

u Other Medications

u Flonase

u Fish Oil

u Started

u 3.75mg/23mg QD x 2 weeks

u 7.5 mg/46 mg QD

u Vit D 50,000 IU weekly

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Bariatric Surgery

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Bariatric Surgery

Sleeve Gastrectomy Gastric Bypass

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Who Qualifies for Surgery?

§ BMI >40 OR BMI >35 with comorbidities§ History of non-surgical weight loss attempts

§ Named diets§ Diet pills§ Counting calories and exercising

§ No psychological contraindications§ NON-SMOKER

§ Tobacco free x 3 months, nicotine free x 2 months

§ DEDICATED TO LIFESTYLE CHANGE

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Operations

• Restrictive-• Laparoscopic vertical sleeve gastrectomy (“the sleeve”)

• Restrictive and Malabsorptive• Laparoscopic Roux en Y gastric bypass (“gastric bypass”)

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Laparoscopic Vertical Sleeve Gastrectomy

v Restrictive Procedure

v Developed early 2000’s

v NOT reversible

v 60-65% excess body weight loss

v ~1.5 hours

v Works by

v Restricting meal size

v Hormonal mechanisms

v Decreased appetite

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Laparoscopic Roux en Y Gastric Bypass

Ø Combination procedure

Ø Long history (1960’s)Ø NOT (easily) reversibleØ 65-75% excess body weight

lossØ ~2.5 - 3 hoursØ Restricts meal sizeØ Hormonal mechanismsØ Reduces appetite

Ø Limits absorption

Duodenum

Pouch

Bypassed Stomach

Roux Limb

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Risks- both procedures

• 0.1% risk of death (1 out of 1000)

• 4% risk of serious complications

• Bleeding

• Deep vein thrombosis (DVT)

• Pulmonary Embolism (PE)

• Wound infections

• Incisional hernias

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Hospital Course

u Day of surgery:

u Out of bed, walking aroundu IV pain medication

u Bariatric clear liquids

u Post op day 1:

u Bariatric clear liquidsu Oral pain medications

u Home on bariatric stage II diet

u Medications liquid or crushed for 1 month after surgery

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Bariatric surgery dietu 2 weeks pre op

u 2 protein shakes per day and 1 reasonable meal

u Post op day 1

u Bariatric Stage I (clear liquids, 30mL advancing to 60mL)

u Post op day 2-14

u Bariatric Stage 2 (full liquids, mostly protein shakes)

u Post op day 15-30

u Bariatric Stage 3 (pureed, baby food consistency)

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Lifetime Changes

• Low fat, low carbohydrate, HIGH protein diet• 60-80 grams of protein per day

• <1000 calories per day• Be active!

• 30 minutes per day, 5 days per week• Daily multivitamin; vit D, B12 & calcium• Social Changes

• No carbonated beverages, no straws• Limit or avoid alcohol, sugary drinks• Stay hydrated (64 ounces of liquids daily)

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Bariatric Case Study

• 61 yo female with Lap band placed in 2010

• Struggled to find her green zone and had limit weight loss• OSA, HTN, OA, HLD, hypothyroid,

mild anxiety• Seeking revision to sleeve

gastrectomy

• Starting weight• 256 lbs. & BMI 40.09

• After 3 month journey to surgery

• 243 lbs. & BMI 38.06

Crestor

Mavik

Lodine

Armour

ZoloftXanax p rn

HTCZ

CPAP

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Post-op follow upu 3 months

u 210 lbs.

u BMI 32.89

u Trip to the zoo

u 6 months

u 187 lbs

u BMI 29.2

u No joint pain & “shopping is FUN again!”

u 9 months

u 172 lbs

u BMI 26.9

u Working out 5 days/week & her husband has joined her and is also losing weight!

Armour

ZoloftXanax p rn

HTCZ

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Andyu 45 yo married AA male

who is a fire fighter

u Came to a bariatric surgery seminar with his wife who was at her PCP that day and discussed her weight

u He decided to have gastric sleeve

u Class III obesity-BMI 41, OSA, GERD, OA

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Andyu 45 yo married AA male who is a fire

fighter

u Weight is down 57 lbsu BMI 33

u Working out 3x/week

u Still adjusting to his new style of eating, eating slower but “thrilled” with his results and how he feels. Doing a great job mindfully meeting protein requirements and taking supplements diligently.

u Preparing for knee surgery and his orthopedic surgeon is also thrilled with his weight loss as this reduces the risk of complications associated with that surgery and improves outcomes

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2 Years After Sleeve: Notice the JOY!

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Take Away Pearls

Medical Weight Management

• Rx therapy indicated

u BMI > 30

u BMI > 27 with comorbidity

• Rx MUST be coupled with behavior modification, dietary counseling & increased physical activity

Bariatric Surgery

• Surgery is indicated with:

u BMI > 40

u BMI > 35 with comorbidity

u HTN, HLD, DM, OSA, OA

• Multi-disciplinary team & ongoing connection with comprehensive program is essential

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ICD-10 Obesity Related Codes

u E66.01 Morbid (severe) obesity due to excess calories

u E66.09 Other obesity due to excess calories

u E66.1 Drug induced obesity

u E66.2 Morbid (severe) obesity with alveolar hypoventilation

u E66.3 Overweight

u E66.8 Other obesity

u E66.9 Obesity, unspecified

u Also include code for BMI (Z68.__)

Other codesZ71.3 Nutritional CounselingE88.81 Metabolic SyndromeR63.2 PolyphagiaR63.5 Abnormal weight gainG47.33 OSA

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Referencesu Bays HE, McCarthy W, Christensen S, Tondt J, Karjoo S, Davisson L, Ng J, Golden A, Burridge K,

Conroy R, Wells S, Umashanker D, Afreen S, DeJesus R, Salter D, Shah N, Richardson L. Obesity Algorithm Slides, presented by the Obesity Medicine Association. www.obesityalgorithm.org. 2020. https://obesitymedicine.org/obesity-algorithm-powerpoint/ (Accessed = Insert date).

u Bloemendaal van L. et al. Effects of glucagon-like peptide 1 on appetite and body weight: focus on the CNS. J Endocrinol 2014;221:T1-T16

u Cardiovascular effects of Glucagon-like peptide 1 (GLP-1) receptor agonists - Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/Pleitropic-effects-of-GLP-1-or-GLP-1R-agonists-Adapted-from-references-24_fig2_267740019 [Accessed 5 Aug, 2018]

u Golden A. Current pharmacotherapies for obesity: A practical perspective. J Am Assoc Nurse Pract. 2017; 29(S1): S43-S52.

u Hess MA, Garvey WT. Assessment and management of patients with obesity

u Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: A report of the American College of Cardiology, American Heart Association Task Force on Practice Guidelines, and The Obesity Society. J Am Coll Cardiol. 2014; 63(25 Pt B); 2985-3023.

u Pereira, Mark A et al.Fast-food habits, weight gain, and insulin resistance (the CARDIA study): 15-year prospective analysis. The Lancet, 2005; 365: 9453 , 36 – 42.

u Reges O, Greenland P, Dicker D, et al. Association of Bariatric Surgery Using Laparoscopic Banding, Roux-en-Y Gastric Bypass, or Laparoscopic Sleeve Gastrectomy vs Usual Care Obesity Management With All-Cause Mortality. JAMA. 2018;319(3):279–290. doi:10.1001/jama.2017.20513

u Trust for America's Health and Robert Wood Johnson Foundation. The State of Obesity 2017 [PDF]. Washington, D.C.: 2017

u 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults, Volume: 129, Issue: 25_suppl_2, Pages: S102-S138, DOI: (10.1161/01.cir.0000437739.71477.ee)

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Resources

u www.asmbs.org

u www.obesitymedicine.orgu www.obesityaction.org

u www.obesity.aace.com

u www.obesity.org

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