Obesity Management in Primary Care€¦ · 2012;31:219-230. Body Weight Pressures to Eat More Pressures to Be Less Physically Biology Active Behavior E in E out Portion Sizes Soft

Obesity Management in Primary Care

© Primary Care Network 1

Linda Davis, MDDirector and Founder

Kolvita Family Medical GroupMission Viejo, CA


Learning Objectives

▪ Discuss the health impact related to obesity and its

associated disease risks

▪ Explain what qualifies as “meaningful” weight loss

and its impact on your patients

▪ Review the FDA approved medications to help

manage obesity

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What is Obesity?

▪ A state of excess adipose tissue mass (Harrison’s: 21st edition)

▪ A chronic, relapsing, multifactorial, 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 Medicine Association)

▪ The WHO definition is:

▪ BMI ≥ 25 is overweight

▪ BMI ≥ 30 is obesity

▪ BMI 30-35 CLASS 1 obesity

▪ BMI 35-40 CLASS 2 obesity

▪ BMI ≥ 40 CLASS 3 obesity

(Avoid the term morbid obesity)

https://accessmedicine.mhmedical.com/content.aspx?bookid=1130&sectionid=79752768 Accessed February 11, 2020

https://obesitymedicine.org/definition-of-obesity/ Accessed February 11, 2020

https://obesitymedicine.org/definition-of-obesity/ Accessed February 11, 2020

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Prevalence† of Self-Reported Obesity Among US Adults by State and Territory, BRFSS, 2011

†Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be compared to prevalence

estimates before 2011. *Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%.

Source: https://www.cdc.gov/obesity/data/prevalence-maps.html

Prevalence† of Self-Reported Obesity Among US Adults by State and Territory, BRFSS, 2018

†Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be compared to prevalence

estimates before 2011. *Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%.


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https://www.cdc.gov/obesity/data/prevalence-maps.html




Prevalence of Self-Reported Obesity Among Hispanic Adults, by State and Territory, BRFSS, 2016-2018

*Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%.


Prevalence of Self-Reported Obesity Among Non-Hispanic Black Adults, by State and Territory, BRFSS, 2016-2018

*Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%.


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Health Impact of Obesity in the United States

▪ Obesity in mid-life shortens life

expectancy by 4-7 years

▪ Medical spending increased in obesity

(2005 values)

▪ Men +$1152/year

▪ Women $3613/year

▪ Obesity medical costs in US $190 Billion,

21% of healthcare expenditures

Peeters A et al. Ann Intern Med. 2003;138:24-32. Cawley J, Meyerhoefer C. J Health Econ. 2012;31:219-230.

Body

Weight

Pressures

to Eat

More

Pressures

to Be

Less

Physically

ActiveBiology

BehaviorEin Eout

Portion Sizes Soft drinks/junk food Variety

High Energy density in schools Convenience

High glycemic index Added Sugar Great Taste

Low Cost Easy food access Ads/marketing

Sedentary

workplaces/schools/

entertainment

Activity “unfriendly”

community design

Drive-through

conveniences

Elevators/escalators

Remote controls

Labor-saving devices

Television/computer

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The Biology Behind Eating

▪ Central Nervous System

▪ Homeostatic system: hunger and satiety

▪ Reward system: over-rides to produce food intake even in absence

of hunger

▪ Peripheral Signals

▪ Leptin from fat

▪ GLP-1, GIP, PYY, OXM, from small intestine

▪ Pancreatic polypeptide, amylin, insulin from pancreas

▪ Ghrelin from stomach

GLP-1 = Glucogen-like peptide 1; GIP = Gastric inhibitory polypeptide;

PYY = Peptide YY; OXM = oxyntomodulin

BMIWeight

Classification

Waist ≤

40” in men or

35” in women

Waist >

40” in men or

35” in women

18.5 or less Underweight -- N/A

18.5 - 24.9 Normal -- N/A

25.0 - 29.9 Overweight Increased High

30.0 - 34.9 Obese High Very High

35.0 - 39.9 Obese Very High Very High

40 or greater Extremely Obese Extremely High Extremely High

Risk of Associated Disease According to BMI and Waist Size

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0.0

0.5

1.0

1.5

2.0

2.5

Folsom AR, et al. Arch Intern Med. 2000;160:2117-2128.

Body Mass Index Tertile

3 2 1

Rela

tive R

isk

Abdominal Fat Distribution Increases the Risk of Coronary Heart Disease

The Iowa Women’s Health Study

A normal waist to hip ratio >0.95 for men and 0.86 for women

Android=Abdominal=

Central=Apple shaped Gynecoid=Peripheral=

Pear shaped

“Apple” vs. “Pear”

Above the

waist

Below

the waist

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Obesity-Related Health Problems

Metabolic effects ▪ Endocrine: Prediabetes and type 2 diabetes, dyslipidemia (low HDL and high triglycerides)

▪ Cardiovascular: HT, CAD, stroke, CHF, AF, venous stasis, DVT, PE

▪ Cancer: Multiple types, most commonly colorectal, postmenopausal breast, and endometrial

▪ Gastrointestinal: GERD, cholelithiasis, nonalcoholic fatty liver disease, nonalcoholic

steatohepatitis

▪ Renal: Nephrolithiasis, proteinuria, chronic kidney disease

▪ Genitourinary:

▪ In women, urinary stress incontinence, polycystic ovarian syndrome, infertility, pregnancy

complications

▪ In men, benign prostatic hypertrophy, erectile dysfunction

▪ Neurologic: Migraine, pseudotumor cerebri

▪ Infections: Greater severity of influenza with severe obesity, skin and soft tissue infections

March 5, 2019 Annals of Internal Medicine In the Clinic ITC35.

Obesity-Related Health Problems

Mechanical effects

▪ Pulmonary: OSA, pulmonary hypertension, restrictive lung

disease, chronic hypoxemic respiratory failure

▪ Musculoskeletal: osteoarthritis, low back pain

Psychosocial effects

▪ Depression and anxiety

▪ Social stigmatization

March 5, 2019 Annals of Internal Medicine In the Clinic ITC35.

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Evaluate for Weight Related Complications at each visit

2013 AHA/ACC/TOS

Guidelines and ACE Guidelines▪ Measure obesity-associated

health risks

▪ Glucose, A1c

▪ Blood pressure

▪ Lipids

▪ Biomechanical problems, joint pain

▪ Sleep apnea

▪ Depression

▪ Cancer history

Jensen MD, et al. 2013 AHA/ACC/TOS Guidelines. J Am Coll Cardiol. 2014;63(25 Pt B):2985-3023.

AHA, American Heart Association

ACC, American College of Cardiology

TOS, The Obesity Society

Being overweight can lead

to high blood pressure and

related complications

▪ Stroke

▪ Blood vessel damage

(arteriosclerosis)

▪ Heart attack or heart failure

▪ Kidney failure

Evaluate and Measure Weight–related Health Risk in Patients

2013 AHA/ACC/TOS Guidelines

▪ Screen all patients with BMI at least annually and more frequently, depending on risk factors

▪ Use waist circumference measure as a risk factor

▪ Identify high risk patients who need to lose weight

▪ BMI ≥30 kg/m2

▪ BMI ≥25 kg/m2 with at least one risk factor

▪ ↑ waist circumference (≥40 inches in men, ≥35 inches in women)

Jensen MD, et al. J Am Coll Cardiol. 2014;63(25 Pt B):2985-3023.

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Case Study - Liz

▪ 44 year old female 5’2” and 199 lbs with BMI of 36 and 36” waist with hyperlipidemia (total cholesterol 220, LDL 154), fatty liver (AST 45, ALT 48) and prediabetes (Hgb A1c 6.2%)

▪ Sedentary lifestyle as medical receptionist with no exercise

▪ Wants help losing weight

How do you approach this patient and where do you start?

Meaningful Weight Loss is Goal

-3.0%

-5.0%

-10.0%

Improvements in glycemic parameters,

reduction of risk for developing diabetes

Greater improvements in above parameters

Improve symptoms of sleep apnea

Greater improvements in glycemic parameters;

improvement in blood pressure, HDL, and triglycerides

Improve markers of NAFLD

Urinary incontinence improves

Even greater improvements in above parameters-15.0%

Jensen MD, et al. J Am Coll Cardiol. 2014;63(25 Pt B):2985-3023.

NAFLD = Nonalcoholic Fatty Liver Disease

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Counsel Patients on Lifestyle Modifications

With or without obesity-related CV factors (NIH, AHA, ACCF, ADA)

Patient success linked to provider suggestions!!!

▪ Prescribe a diet

▪ To achieve reduced caloric intake

▪ Refer to professional or evidence-

based program

▪ Increase physical activity

▪ Lifestyle intervention program

Powell-Wiley TM, et al. Obesity. 2012; 20;849-855.

NIH, National Institute of Health; AHA, American Heart Association

ACCF, The American College of Cardiology Foundation; ADA, American Diabetes Association

Components of an Effective Obesity Management Program

Wadden TA, et al. Med Clin North Am. 2000;84:441-461.Stumbo, PH, et. al. Surg Clin N Am. 85(2005)703-723.

Surgery or Medications

Physical Activity

Behavior Modification

Diet

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Look AHEAD Research Group. Arch Intern Med. 2010;170:1566-1575.

How Much Weight Does the State-of-the-Art Lifestyle Intervention Produce?

-0.63 -0.93 -0.92

-1.010.00

-8.5

-6.35

-5.04

-4.66

-9

-8

-7

-6

-5

-4

-3

-2

-1

0Year 0 Year 1 Year 2 Year 3 Year 4

Mean weight loss (%) from baseline by year

Diabetes support and education

ILI, Intenstive lifestyle intervention

% W

eig

ht

ch

an

ge

P<.0001

“Diet” vs “Lifestyle Change”

▪ Diets are thought of as temporary – lifestyle changes are long term – “forever”

▪ Reduce caloric intake 500-750 kcal/day – (take into consideration output - if caloric input exceeds output weight gain will occur)

▪ Commercial programs (eg. Jenny Craig, WW, Nutrisystem) can produce weight loss

▪ Detox/Cleanses/Weight Loss Supplements – Not FDA vetted/approved – often contain some sort of stimulant (caffeine derivative), effects often short term

▪ With regards to weight loss – no diet has been proven superior to others

▪ With regards to health – specific dietary patterns have good evidence for primary and secondary prevention of several chronic diseases

▪ Prevention of cardiovascular disease, cancer, type 2 diabetes mellitus, and obesity

▪ Mediterranean diet, the Dietary Approaches to Stop Hypertension diet (DASH), the 2015 Dietary Guidelines for Americans, and the Healthy Eating Plate

Diets for Health Goals and Guidelines: AMY LOCKE, MD, University of Utah Health, Salt Lake City, Utah, JILL SCHNEIDERHAN, MD, University of Michigan

Medical School, Ann Arbor, Michigan, SUZANNA M. ZICK, ND, MPH, University of Michigan School of Public Health, Ann Arbor, Michigan Am Fam

Physician. 2018 Jun 1;97(11):721-728.

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The Mediterranean Diet

▪ Not a specific diet but rather recommendations based on observations

of what people eat that live in the regions surrounding the

Mediterranean Sea

▪ The main components of Mediterranean diet include:

▪ Daily consumption of vegetables, fruits, whole grains and healthy fats (ie, olive oil)

▪ Weekly intake of fish, poultry, beans and eggs

▪ Moderate portions of dairy products (Greek yogurt)

▪ Limited intake of red meat

▪ Red wine in moderation (risks vs benefits…)

Intermittent Fasting

▪ Based on timed periods of little/no caloric intake (without reducing vital nutrients)

▪ Triggers the body to shift from utilizing glucose in the liver for energy to ketones stored in fat - “ketogenesis”

▪ Ketogenesis – reduces oxidative/metabolic stress and promotes/enhances cellular repair/healing

▪ Short term studies demonstrate improvements in obesity, diabetes, cardiovascular disease, cancers and neurological disorders. Long term (longevity outcomes) not known

▪ Examples:

▪ Alternate day fasting, 5:2 intermittent fasting (fasting two days each week)

▪ Daily time-restricted feeding (such as eating only during a six-hour window)

De Cabo R and Mattson MP. Effects of intermittent fasting on health, aging, and disease. New England Journal of Medicine. 2019;381(26):2541-2551.

doi: 10.1056/NEJMra1905136.

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https://www.nejm.org/doi/full/10.1056/NEJMx190038



Implementing Intermittent Fasting

Month Time-Restricted Feeding 5:2 Intermittent Fasting

Month 1 10 hour feeding period 5 days/week 1000 calories 1 day/week

Month 2 8 hour feeding period 5 days/week 1000 calories 2 days/week

Month 3 6 hour feeding period 5 days/week 750 calories 2 days/week

Month 4 (goal) 6 hour feeding period 7 days/week 500 calories 2 days/week

De Cabo R and Mattson MP. Effects of intermittent fasting on health, aging, and disease. New England Journal of Medicine. 2019;381(26):2541-2551.

doi: 10.1056/NEJMra1905136.

Diet Composition Comparison:Weight Change From Baseline

-5

-4.5

-4

-3.5

-3

-2.5

-2

-1.5

-1

-0.5

0

Protein Fat Carb

High Low

High-low:(P=0.22)

High-low:(P=0.94)

We

igh

t Lo

ss (

Kg)

High-low:(P=0.42)

Sacks FM, et al. N Engl J Med. 2009;360:859-873.

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https://www.nejm.org/doi/full/10.1056/NEJMx190038



Exercise – Move your body!

▪ The best form of exercise . . . Is the one you will do!!

▪ Exercise can help with weight loss as well as help maintain

weight loss

▪ Increases metabolism = more calories burned per day

▪ Increases muscle/lean body mass

▪ Increases insulin sensitivity

▪ Releases endorphins

▪ Combined with diet –

more effective for weight loss

then either independently

Exercise Recommendations

▪ For General Health

▪ Moderate intensity physical activity or equivalent*

▪ 150 minutes/week

▪ Resistance training

▪ Moderate or high intensity

▪ 2 or more days a week

▪ Weight Loss and Maintenance

▪ 150 to 250 minutes per week moderate intensity

▪ 250 minutes or more per week for maintenance

*Defined as activities that are strenuous enough to burn three to six times as much energy per minute as an individual would burn when sitting quietly,

or 3 to 6 METs (metabolic equivalents). Vigorous-intensity activities burn more than 6 METs.

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Case Study - Liz

▪ 44 year old female with BMI of 36 and 36” waist with hyperlipidemia, fatty liver, and prediabetes

▪ Sedentary lifestyle as medical receptionist with no exercise

▪ Wants help losing weight

▪ After 6 months with Jenny Craig and walking 2 miles 4 x per week:

▪ 8 lb weight loss now 191 and BMI of 35, waist 35”

▪ Total Cholesterol 202, LDL 138, AST/ALT now normal, hgb A1c 5.9%

She feels frustrated, was hoping for more weight loss.

Additional history: Has 2 children (s/p BTL), told she has gallstones, takes Tramadol 50mg BID for chronic spinal stenosis of lumbar spine.

What is your next step?

Efficacy and Safety of Currently Available Treatments

Lifestyle1 Gastric Band3

Gastric

Bypass3

0% 5% 10% 15% 20% 25% 30% 35% Weight Loss

1. Jensen MD, et al., Circulation. 2014;129(25 Suppl 2):S102-138.

2. Courcoulas AP, et al. JAMA. 2013;310:2416-2425.

3. LABS consortium. N Engl J Med 2009;361:445-54.

4. Colman E, et al. N Engl J Med. 2012;367:1577-1579.

Perioperative DVT, thromboembolism or death2

1% for gastric band

5% for bypass

Meds +

Lifestyle4

Weight loss at 3 years3

16% for gastric band

33% for bypass2

VLCD

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Meds Don’t Work on Their OwnImportant to Use Medication as an Adjunct to Lifestyle Counseling

▪ Lifestyle-modification alone

▪ Combined therapy

▪ Sibutramine alone

▪ Sibutramine + brief therapy

Mean weight loss, kgN=224

5.0 ± 7.4

6.7 ± 7.9

7.5 ± 8.0

12.1 ± 9.8

Wadden TA, et al. N Engl J Med. 2005;353:2111–2120.

0

2

4

6

8

10

12

14

16

0 3 6 10 18 40 52

Weeks

Wei

ght

loss

(kg

)

Why Do We Need Medication for Weight Loss?

Address some pathophysiological problems

▪ Adherence to healthy eating plan

▪ Achieve meaningful weight loss

▪ Produce more weight loss –

greater health benefits

▪ Early weight loss = more success

▪ Sustain weight loss

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What can weight loss medications do?

▪ Help struggling patients achieve health benefits

▪ Serve as adjunct to lifestyle modifications

▪ Achieve greater meaningful weight loss

▪ Achieve weight loss early to promote long-term success

Pharmacotherapies

Agents Action Approval, Availability

Phentermine

(Adipex-P)

• Central noradrenergic agent

• Schedule II–IV

• Approved, 1959

• #1 seller in US

• 3-month prescribing limit

Orlistat

(Xenical; Alli)

• Peripheral pancreatic lipase

inhibitor

• Blocks fat absorption

• Not scheduled

• Approved, 1999

• Available in US, EU

• Available OTC or prescription

Kushner RF. Expert Opin Pharmacother. 2008;9:1339-1350.

Phentermine. [prescribing information]. Sellersville, PA: Teva Pharmaceuticals. http://www.accessdata.fda.gov/drugsatfda_docs/label/2012/085128s065lbl.pdf

Orlistat [prescribing information]. San Francisco, CA: Genentech;2013. https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/020766s026lbl.pdf

Orlistat [package insert]. Moon Township, PA. GlaxoSmithKline, 2011.

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Pharmacotherapiescontinued

Kushner RF. Expert Opin Pharmacother. 2008;9:1339–1350.

Phentermine/topiramate ER [prescribing information]. Mountain View, CA: Vivus Inc.,2012. https://www.qsymia.com/pdf/prescribing-information.pdf

Lorcaserin hydrochloride [package insert]. Woodcliff Lake, NJ: Eisai Inc.; 2012. https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/022529lbl.pdf


Lorcaserin

(Belviq, Belviq XR)

• 5-HT2C serotonin agonist

• Little affinity for other serotonergic receptors

• Approved, summer 2012

• Recalled February 2020 –due to increased cancer risk (pancreatic, colorectal, and lung)

Phentermine/Topiramate ER

(Qsymia)

• Sympathomimetic

• Anticonvulsant (GABA receptor modulation, carbonic anhydrase inhibition, glutamate antagonism)

• Approved, summer 2012

Pharmacotherapiescontinued


Naltrexone HCl/Bupropion HCl

(Contrave)

• Opioid antagonist

• Neuronal reuptake inhibitor of dopamine and norepinephrine

• Approved, September 2014

Liraglutide 3 mg

(Saxenda)

• GLP-1 Receptor agonist

• Augments insulin secretion during hyperglycemia, suppresses appetite, and delays gastric emptying

• FDA-approved in 2010 for

diabetes (1.8 mg/day)

• FDA AdCom voted 14-1 in favor of

approval of high-dose (3.0 mg/

day) for obesity on September 11,

2014

• Approved, December 2014

Naltrexone HCl/Bupropion HCl [package insert]. Deerfield, IL; Takeda Pharmaceuticals Intl. Inc. 2014.

https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/200063s000lbl.pdf

https://www.ajmc.com/journals/evidence-based-diabetes-management/2015/january-2015/liraglutide-approved-under-new-name-to-treat-obesity

Accessed February 17, 2020

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Phentermine/Topiramate ER

▪ Initially titrate: 3.75/23 mg → 7.5/46 mg

▪ Option to escalate to 15/92 mg with low weight loss response

▪ Contraindications

▪ Pregnancy

▪ Glaucoma

▪ Hyperthyroidism

▪ Monoamine oxidase inhibitors

Effect of Phentermine/Topiramate Extended Release on Weight Loss in Obese

Adults Over 2 Years: SEQUEL

Garvey WT, et al. Am J Clin Nutr. 2012;95:297–308.

-10.5%*

0

–12

–14

–16

–10

–8

–6

–4

–2

Weeks

LS m

ean

wei

ght

loss

(%

)

0 8 12 16 20 24 28 32 36 40 44 48 52 56 60 64 68 72 76 80 84 88 92 96 100 104 108 LOCF

-1.8%

-9.3%*

*p<0.0001 vs. placeboPlacebo PHEN/TPM ER 7.5/46 PHEN/TPM ER 15/92

Results are for the completer population; presented as least-squares mean (95% CI).

Data to the right are for the ITT LOCF population. PHEN/TPM ER = phentermine/topiramate combination therapy

ITT = intent to treat

LOCF = last observation carried forward

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Orlistat

Indications and DoseApproved by FDA, 1999

▪ Approved in adolescents

▪ Dosing:

▪ Rx: 120 mg TID with each meal

▪ OTC: 60 mg TID with each meal

▪ Advise patients:

▪ Nutritionally balanced, reduced-calorie diet; approximately 30% of calories from fat

▪ Take a multivitamin containing fat-soluble vitamins at bedtime

Contraindications and Warnings▪ Contraindications:

▪ Pregnancy, chronic malabsorption syndrome, cholestasis

▪ Warnings:

▪ Decrease cyclosporine exposure, rare cases of severe liver injury, increased levels of urinary oxalate

▪ GI AEs: oily spotting, flatus with discharge, fecal urgency, fatty/oily stool, oily evacuation, increased defecation and fecal incontinence

Orlistat [prescribing information]. San Francisco, CA: Genentech;2013. https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/020766s026lbl.pdf

Orlistat [package insert]. Moon Township, PA. GlaxoSmithKline, 2011.

Naltrexone HCL/Bupropion HCL

Use

▪ Dose escalation required up to

4 week period

▪ Bupropion, antidepressant

(Wellbutrin), requires monitoring

for worsening and emergence of

suicidal thoughts

▪ Contraindicated in uncontrolled

HTN, seizures, chronic opioid

use, and pregnancy

Light Study

▪ Nearly 9,000 overweight/obese

patients with CVD risk factors

▪ Rule out excess cardiovascular

risk in overweight and obese

receiving NB

▪ Interim analysis found no

differences in SBP, DBP,

Heart rate

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Naltrexone SR/Bupropion SR Body Weight Change

Greenway FL, et al for the COR-I Study Group. Lancet. 2010;376(9741):595-605.

Liraglutide

▪ Daily injectable

▪ 3 mg dose (1.8 mg used in type 2 diabetes)

▪ Potential risk of medullary thyroid carcinoma (MTC)

▪ Pancreatitis risk

▪ Gallbladder risk

▪ Main side effects: nausea, vomiting

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Scale Liraglutide Maintenance Study

Wadden TA, et al. Int J Obes (Lond). 2013;37:1443-1451.

Liraglutide with Diet/Exercise at 2 years

0

10

20

30

40

50

60

5% or more 10% or more

liraglutide

Placebo

Adverse Events, %

Placebo

(n=98)

Liraglutide 3.0

(n=93)

Constipation 12.2 18.3

Diarrhea 10.2 15.1

Dyspepsia 3.1 8.6

Nausea 7.1 48.4

Vomiting 2.0 12.9

Psychiatric 5.1 12.9

Liraglutide 2.4/3.0, liraglutide 2.4 mg and 3.0 mg pooled

Astrup A, et al for the NN8022-1807 Investigators. Int J Obesity. 2012;36:843-854.

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Reducing Body Weight by % Categories at 1 Year with Adjunctive Medication Among those who

Complete Treatment*

0

10

20

30

40

50

60

70

80

90

100

Phen/TPM 7.5/46 Phen/TPM 15/92 lorcaserin 10 BID bupropion/naltrexone32/360

liraglutide 3.0

5% weight loss 10% weight loss

*Combined with lifestyle modification; data are from largest Phase III trial

Perc

enta

ge

, %

Medications: Side Effects and ConsiderationsTrial Most Common Side Effects Considerations

Phentermine-Topiramate ER

Dry mouth 13.5%

Tingling 13.7%

Constipation 15.1%

Altered taste 7.4%

MAOIs; Acute Myopia and Secondary Angle

Closure Glaucoma, hyperthyroidism,

oxalate kidney stones, teratogenic

Orlistat

Oily Spotting Yr 1: 26.6% Yr 2: 4.4%

Flatus with Discharge 23.9% 2.1%

Fecal Urgency 22.1% 2.8%

Fatty/Oily Stool 20% 5.5%

Oily Evacuation 11.9% 2.3%

Increased Defecation 10.8% 2.6%

Fecal Incontinence 7.7% 1.8%

Pregnancy, chronic malabsorption,

cholestasis, known hypersensitivity reaction

Bupropion-Naltrexone

Nausea 32.5%

Constipation 19.2%

Headache 17.6%

Vomiting 10.7%

Dizziness 9.9%

Insomnia 9.2%

MAOIs; Seizure disorders, chronic opioid

use, suicidal thinking, anorexia nervosa or

bulimia, other bupropion-containing

products

Liraglutide

Nausea 39.3%

Diarrhea 20.9%

Constipation 19.4%

Vomiting 15.7%

Headache 13.6%

Potential risk of medullary thyroid carcinoma

(MTC), pancreatitis, gall bladder disease

Phentermine/topiramate ER [prescribing information]. Mountain View, CA: Vivus Inc.,2012. https://www.qsymia.com/pdf/prescribing-information.pdf

Orlistat [prescribing information] 2017 CHEPLAPHARM Arzneimittel GmbH. https://xenical.com/pdf/PI_Xenical-brand_FINAL.PDF

Naltrexone HCl/Bupropion HCl [package insert]. Deerfield, IL; Takeda Pharmaceuticals Intl. Inc. 2014. https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/200063s000lbl.pdf

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Case Study - Liz

▪ Diet: Continue with current membership with Jenny Craig

or consider intermittent fasting?

▪ Exercise: 2 miles 4x/week on average = 120-160 min/week

▪ Depending on intake may need to increase?

▪ Medication:

▪ Orlistat Y/N

▪ Naltrexone/Bupropion Y/N

▪ Phentermine/Topiramate Y/N

▪ Liraglutide Y/N

Surgery???

Role of Bariatric Surgery in Obesity and Associated Metabolic Conditions

▪ Studies show that bariatric surgery causes significant weight loss

and is more effective at improving diabetes in the short term (up

to 2 years) than nonsurgical interventions (diet, exercise, other

behavioral interventions, and medications)

▪ Diabetes improvement starts rapidly after surgery, before

significant weight loss has occurred

▪ The mechanism for postoperative metabolic improvements has

not been fully elucidated and may be, in part, independent of

weight loss Buchwald H, Estok R, Fahrbach K, et al. Am J Med. 2009 Mar;122(3):248-256. PMID: 19272486.

Maglione MA, Gibbons MM, Livhits M, et al. AHRQ Comparative Effectiveness Review No. 82.

Available at https://effectivehealthcare.ahrq.gov/sites/default/files/related_files/weight-loss-surgery_executive.pdf

Mingrone G, Panunzi S, De Gaetano A, et al. N Engl J Med. 2012 Mar 26;366(17):1577-85. PMID: 22449317.

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Indications for Surgery

Indications are consensus based and vary between organizations.

All agree to consider surgery on patients with a BMI ≥ 40 or more

than 100 pounds to lose or a BMI ≥ 35 and other significant co-

morbidities.

Other possible indications include:

▪ Patients who have failed other

attempts to maintain a healthy weight

▪ Lower weight patients with

uncontrolled T2D

Is the Patient a Surgical Candidate?

Beyond meeting NIH/insurance criteria, is the patient...

▪ Motivated to change?

▪ Demonstrating change, already?

▪ Aware of the post-surgical requirements (diet/exercise/vitamins)?

▪ Able to keep post-bariatric visits?

▪ Capable of understanding the process?

▪ Able to afford the required food & vitamins?

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Improvement of Comorbidities

▪ Weight loss surgery reliably induces rapid, marked, and

durable weight loss among obese patients

▪ Reduces the burden of multiple obesity-associated

comorbidities including diabetes, OSA, cardiovascular

disease including hypertension, stroke, coronary artery

disease and heart failure

▪ May protect against malignancy

Improved Survival with Weight Loss Surgery

▪ Weight loss surgery patients were prospectively matched to a

control group of 2,037 patients who underwent standard medical

therapy, the risk-adjusted hazard ratio for mortality was 0.71 after a

mean follow up of 10.9 years

▪ A retrospective analysis that matched 2,500 weight loss surgery

patients to 7,462 matched controls in the United States Veterans

Affairs system found that surgical patients had significantly

decreased mortality after one year of follow up, with a hazard ratio

of 0.47 after 5 years

Reges O, Greenland P, Dicker D, Leibowitz M, Hoshen M, Gofer I, 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;319:279–90.

Sjostrom L, Narbro K, Sjostrom CD, Karason K, Larsson B, Wedel H, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J

Med 2007;357: 741–52.

Arterburn DE, Olsen MK, Smith VA, Livingston EH, Van Scoyoc L, Yancy WS, et al. Association between bariatric surgery and long-term survival. JAMA

2015;313: 62–70.

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Common Bariatric or Weight Loss Surgeries (WLS)

Adapted from an illustration by Walter Pories, MD, FACS

Follow Up on WLS Patients

▪ At 6 months post expect

▪ ~30-40% Excess Body Weight (EBW) loss

▪ At 12 months post expect

▪ RYGB: 55-70%

▪ Sleeve: 45-60%

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Follow Up on WLS Patients

▪ Diet: General composition guidelines

▪ 70 - 80 gm of protein

▪ Protein > vegetables > fruit > carbs

▪ 64 oz of water/equivalents

▪ No carbonation

▪ Avoid: bread/rice/pasta

▪ Avoid sweetened beverages

Obesity in Children

▪ Growing global health issue (especially in

US and other developed countries)

▪ No clear cut recommendations on

approach to treatment

▪ Societal barriers (socioeconomics, cultural,

environmental)

▪ No FDA approved medications for children

▪ Pediatric Obesity Algorithm originally sponsored by Obesity Medical

Association in 2016 to try to address this care gap and uncertainty.

Available online at: www.Pediatricobesityalgorithm.org

▪ Identifying and classifying these children as early as possible is important,

as is identifying comorbid conditions

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http://www.pediatricobesityalgorithm.org/



Obesity by Race/Sex

▪ Non-Hispanic blacks

(49.6%) had the highest

age-adjusted prevalence of

obesity, followed by

Hispanics (44.8%), non-

Hispanic whites (42.2%)

and non-Hispanic Asians

(17.4%)

https://www.cdc.gov/nchs/data/databriefs/db360_tables-508.pdf#page=2

SOURCE: NCHS, National Health and Nutrition Examination Survey, 2017–2018.

1Significantly different from all other race and Hispanic-origin groups.2Significantly different from men for same race and Hispanic-origin group.

NOTES: Estimates were age adjusted by the direct method to the 2000 U.S. Census population using the age groups 20–39, 40–59, and

60 and over.

Obesity in Pregnancy

▪ Increased risk for:

▪ Miscarriage

▪ Gestational Diabetes

▪ Macrosomia

▪ Preeclampsia

▪ Birth defects - babies born to obese women have an increased risk of

having birth defects, such as heart defects and neural tube defects

▪ Stillbirth - the higher the woman’s BMI, the greater the risk of stillbirth

Source: https://www.acog.org/patient-resources/faqs/pregnancy/obesity-and-pregnancy

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https://www.cdc.gov/nchs/data/databriefs/db360_tables-508.pdf#page=2



Summary

▪ Obesity is endemic in the US & the world, and the prevalence

is growing

▪ It is easy to diagnose, easy to stigmatize, and difficult to treat

▪ Obesity is a chronic medical condition requiring ongoing care

▪ Associated with multiple serious health risks

▪ Multi-disciplinary approach of diet, exercise, and lifestyle

changes remain the backbone of therapy. Close follow-up

improves outcomes

▪ Consider implementing medications earlier as indicated

▪ More serious cases need more serious intervention

▪ Even modest weight loss can significantly effect morbidity and

impact on medical outcomes

Early Intervention! Don’t wait until BMI of 30 to start the

discussion with your patients.

Summary

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Documents

Obesity Management in Primary Care€¦ · 2012;31:219-230. Body Weight Pressures to Eat More Pressures to Be Less Physically Biology Active Behavior E in E out Portion Sizes Soft