2/19/20
1
Tackling the Obesity EpidemicTNP Spring 2020
Susan Bowlin, MSN, APRN, FNP-BC, ACNP-BC, CBN
1
Disclosures
o None
2
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.
3 4
THE DISEASE OF OBESITY
5
2 Years After Sleeve: Notice the JOY!
6
6
2/19/20
2
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
7
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.
8
8
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.
9
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.
10
11
National Obesity TrendsNational Health and Nutrition Examination Survey (NHANES), 2011-2014 data
GENDER AGE ETHNICITY
12
2/19/20
3
Texas Obesity Rates: 33.7% Ranking 8th/51
0
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
13
Effects of BMI and Smoking Status on Survival
Men 35-100 years old
N Engl J Med 2010; 362:855-857
14
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
15
Is This Our Future… Obesity of Tomorrow?
Prevalence of Obesity Among U.S. Adults Ages 20-74
16
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
17
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
18
2/19/20
4
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?
19
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
20
Influences of Our Times
Patient
Portions
Family Schedule
Work Schedule
Business Meals
Eating Out
Distractions
21
CAN YOU RELATE?
22
22
Convenience Crisis
23
Convenient Abundance
24
2/19/20
5
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
25
Classifications
26
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
26
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)
27
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
28
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
29
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.
30
2/19/20
6
Obesity Comorbidities…actually…complications
31
Comorbidities of Obesity
32
32
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
33
Physical Exam Findings
Increased neck circumference
Modified mallampati score of 3 or 4
Tonsillar hypertrophy/enlarged uvula
Peripheral edema
Cardiac dysrhythmia
HTN
34
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!
35
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?
36
2/19/20
7
Popular diets
Ketogenics Paleo Atkins Mediterranean
OrnishDASH (Dietary
Approaches to Stop HTN)
Commercial Diet programs• Weight Watcher’s• Nutrisystem
• Jenny Craig
37
Hunger, appetite and satiety
38
Tools/Questionnaires'
STOP-Bang Questionnaire
Screen for sleep apnea
QOL Indicator
2018 PAR-Q+ to establish exercise readiness
39
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
40
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.
41
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
42
2/19/20
8
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
43
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
44
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
45
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
46
MOTIVATIONAL INTERVIEWING
47
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.
48
2/19/20
9
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.
49
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.
50
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
51
HUNGERHORMONE REGULATION
52
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
53
Hunger Hormones
54
2/19/20
10
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]
55 56
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
57
Goals of Treatment
58
ANTI-OBESITYMEDICATIONS(AOMS)
59
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
60
2/19/20
11
Anti-obesity Medications (AOBMs)Pharmacotherapy
Adipex
Belviq
Qysmia
ContraveSaxenda
FDA pulled off market due to potential increase cancer rates
61
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.
62
63
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)
64
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)
65
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
66
2/19/20
12
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
67
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
68
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.
69
L van Bloemendaal et al. J Endocrinol 2014;221:T1-T16
GLP-1 & Glucose metabolism
70
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
71
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
72
2/19/20
13
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
73
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.
74
74
Anti-Obesity PharmacologyDual Benefits
Obesity along with: May consider:
Diabetes Saxenda
Migraines Qysmia
Depression Contrave
Smoking Contrave
75
AOM Case Studies
76
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
77
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
78
2/19/20
14
Barbara64 year old
u Hx/ouBack pain: recently
had stimulator placed
uAsthmauSkin canceruMild
depression/anxiety
u RXuTizanidineuAdzenysuXanax prnuWellbutrinuPregavalinuZolpidem
79
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
80
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.
81
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!
82
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
83
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
84
2/19/20
15
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
85
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
86
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
87
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
88
Bariatric Surgery
89
Bariatric Surgery
Sleeve Gastrectomy Gastric Bypass
90
2/19/20
16
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
91
Operations
• Restrictive-• Laparoscopic vertical sleeve gastrectomy (“the sleeve”)
• Restrictive and Malabsorptive• Laparoscopic Roux en Y gastric bypass (“gastric bypass”)
92
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
93
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
94
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
95
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
96
2/19/20
17
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)
97
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)
98
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
99
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
100
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
101
101
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
102
102
2/19/20
18
2 Years After Sleeve: Notice the JOY!
103
103
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
104
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
105
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)
106
Resources
u www.asmbs.org
u www.obesitymedicine.orgu www.obesityaction.org
u www.obesity.aace.com
u www.obesity.org
107