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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.
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• 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.
Questions
• We encourage the use of person-first language
• “adults with obesity” and not “obese adults”
