Treatment of Obesity SAJIDA AHAD MERCY GENERAL SURGERY
Treatment of ObesitySAJIDA AHAD
MERCY GENERAL SURGERY
Objectives
1. Learn classification and evaluation of overweight and obese patient
2. Discuss impact of voluntary weight loss on morbidity and mortality
3. Review resources for treatment of obesity in primary care setting
4. Update on bariatric surgery
Why care about obesity?
Obesity is a global public health concern
Prevalence of obesity in the United States: 35% among men and 40% among women Compared to 25 years ago when less than 15% of the nation was considered obese
The obesity epidemic has placed an economic burden on the US health care system
In 2013, obesity was officially recognized as a disease state by the American Medical Association
World Health Organization (WHO) defines body mass index (BMI)as follows Normal = 18.5 to 24.9
Overweight =25 to 29.9
Obese >30
class I =30 to 34.9
class II =35 to 39.9
class III = 40 and above
Classification and evaluation of
overweight and obese patients
Clinical classification
Size and number of fat cells
In adults, upper limits of the total of normal fat cells range from 40-60 billion
The number of fact cell increase most rapidly during late childhood and puberty
The number of fat cells can increase 3-5 fold with obesity occurs in childhood or adolescence
Hypertrophic obesity
Large fat cells correlate with android or truncal fat distribution
This condition is often associated with metabolic disorders such as glucose intolerance, dyslipidemia,
hypertension and coronary artery disease
Fat distribution
Fat distribution is important because increased visceral fat predict the development of health
risks better than total body fat
Waist circumference
CT
MRI
Waist circumference(WC)
WC has been shown to be a strong correlate of intra-abdominal adipose
tissue in diverse race/ethnic groups
WC is very strongly related to total adiposity and Visceral adiposity
Visceral fat is associated with many metabolic risk factors, metabolic
syndrome, diabetes, and CAD
cutoff values for WC (90 cm for men and 83 cm for women) that are equivalent to a BMI of 25 kg/m2 might represent appropriate action levels
for counseling patients to limit further weight gain
Natural history of obesity
Individuals can become overweight at any age
One third of the overweight adults do so before age 20
Predictors of weight gain
Incidence of diabetic mother R mother who smoked
Overweight parents
Overweight in childhood
Lower education or income group
Cessation of smoking
Sedentary lifestyle
Low metabolic rate
Lack of maternal knowledge of child’s sweets eating habits
Recent marriage
Multiple births
Cost of obesity
The economic cost of obesity
The cost-effectiveness of treatment modalities
Economic cost of obesity
Direct Medical Cost
-direct treatment of obesity and related disease e.g. DM and HTN
-include medications and surgical procedures
Direct Non Medical Cost
-expense of health education
-expense of maintaining healthy life style
-preventing obesity
-not paid for by healthcare systems
Indirect Cost
-time lost from employment
-time lost by family and friends
Cost of Obesity (contd)
In USA, estimated cost of obesity ranges from $26.6 to $ 70 Billion
Upto 7 % of annual healthcare expenditures
Majority of the cost is treating obesity related conditions rather than obesity itself
Cost to employers
❑ Medical charges for obese employees 69% higher than non obese employees
❑ Obese employees use twice as many sick leave days as normal weight employees
Cost to individuals
❑ Shorter life expectancy
❑ Lower health related quality of life
❑ Cost of weigh management and control($66 billion market)
Cost effectiveness of obesity
interventions
A physician weight loss advice is associated with both fewer calories and
fat intake and more exercise to lose weight
Weigh WatchersTM might be cost-effective because of its demonstrated
effectiveness and the moderate cost
Medically supervised programs are expensive, but achieve more weight
loss than Weight Watchers in the best scenario
Although there is insufficient evidence for the effectiveness of weight loss
of inexpensive self-help programs and Internet-based programs, they are
potentially cost-effective if the weight loss goal can be achieved
Voluntary weight loss
voluntary weight loss is considered central to the clinical and public health
response to prevent obesity
Barriers
1. Perceived ineffective
2. Epidemiological concern with increased mortality
3. Broad ramifications
more than a 1/3 adults and more than 2/3 obese adults are trying to lose weight at
any given time
huge potential of interventions to positively affect health or, waste resources
Strategies for voluntary weight loss
used by patients
most people have a weight loss goal of <10 kg, but about one-fourth would like to lose 15 kg or more
only one-fifth report the recommended combination of eating fewer calories and exercising >150 min/wk
other methods used
▪ skipping meals (17%)
▪ attending special programs (7%)
▪ eating special products (22%)
▪ taking supplements or diet pills (14%)
▪ fasting(3%)
▪ purging (3%)
structured weight loss programs
advantage of providing stronger evidence about the cause and effect,
dose response, and clinical utility of weight loss interventions
limitation is that it frequently test interventions that are either not practical
in the real world and/or do not reflect the real ways that people in the
community go about weight loss
Unknown net effect in the population
Effect on diseases
Weight loss affect long-term disease incidence and mortality
most direct and important effects on insulin sensitivity, glucose tolerance, blood pressure, lipid parameters, and inflammatory factors
A 5 kg reduction in weight causes
▪ Drop of 4 mmHg systolic blood pressure
▪ Drop of 3 mmHg of diastolic blood pressure
▪ Decrease of 5 to 8 mg/dL of total and low-density lipoprotein (LDL) cholesterol
▪ Decrease of 18 mg/dL of triglyceride
Weight loss reduces left ventricular hypertrophy , resting heart rate, increases stroke volume and cardiac output, improves coagulation and fibrinolytic factors, reduces angina symptoms, and consistently improves functional status
Decrease in inflammatory markers
Improvement in HbA1c
Is short term weight loss beneficial?
most people who try to lose weight regain weight
on average, one-third of peak weight loss is regained in the year following weight loss
unclear whether the physiological benefits are maintained over a long-enough period of time to reverse preexisting pathology and thus influence long-term health outcomes
weight loss is associated with increased bone loss, decreased lean muscle mass, gallstone development, and perhaps, decreased immunity associated with multiple weight loss attempts
The reduction in bone loss may be offset by increased physical activity, but concerning in older adults
Strong and consistent evidence relates intentional weight loss to reduced
incidence of diabetes among high-risk individuals
Intentional weight loss has been consistently associated with reduced
incidence of hypertension and improved control of blood pressure
Weight loss may reduce disability and improve mobility and functioning in
daily living among older populations
Increasing evidence suggests that intentional weight loss reduces overall
mortality and possibly CVD incidence
Obesity and Primary Care
Obesity is one of the most common medical problem seen by Primary
Care Physicians
these patients are also more likely to present with other diseases, e.g.,
hypertension, dyslipidemia, type 2 diabetes, metabolic syndrome
In practice, however, obesity is underrecognized and undertreated in the
primary care setting
Failure to adequately identify the overweight and mildly obese patient,
however greater recognition for the moderately to severely obese patient
less than half of obese adults are being advised to lose weight by health
care professionals
Office-Based Obesity Care
Health care system geared to treating acute care problems rather than
chronic conditions
Obesity is a chronic condition
Physical
environment
Accessibility and comfort, space, reading and
educational material
Equipment Large BP cuffs, large gowns, Step stools, higher
limit scales
Materials Educational handouts on diet, exercise,
medications, surgery, www.choosemyplate.gov
Tools Pre-visit questionnaires, Fitness trackers, apps
Protocols Return visit, medications, referral to
surgery,dietitian and psychologists
Treating obesity
Measure height and weight
BMI
Measure waist circumference
assess comorbidities
Look for causes of obesity including the use of medications
Is the patient ready and motivated to lose weight?
If the patient is not ready to lose weight, urge weight maintenance and manage the complications
If the patient is ready, agree with the patient on reasonable weight and activity goals and document
Involve other professionals(dietitians, therapists, structured programs)
Guide to selecting treatment
Treatment 25-26.9 27-29.9 30-
34.9
35-39.9 >40
Diet, exercise,
behavior therapy
With
comorbidities
With
comorbidities
+ + +
Pharmacotherapy + + +
Surgery With
comorbidities
+
Pharmacotherapy
Antiobesity pharmacotherapy should be considered as an adjunct to diet
and behavioral modification
facilitates weight loss or promote long-term weight maintenance
Potentially treat comorbid conditions associated with obesity, including
prediabetes, type 2 diabetes mellitus (T2D), obstructive sleep apnea,
hypertension, and dyslipidemia
expected weight loss from obesity pharmacotherapy is 5% to 10% of total
body weight (TBW)
For patients with severe obesity (class III), multiple medications , in addition
to surgical intervention may be considered
Phentermine
Phentermine was approved by the FDA in 1959
Most commonly prescribed short-term (up to 12 weeks) medication for
weight loss Phentermine is primarily
Standard adult dose is up to 37.5 mg daily before breakfast
Use lowest effective dose first
side effects: dizziness, dry mouth, difficulty sleeping, and irritability
Orlistat
Approved in 1999 by the
Orlistat alters fat digestion by inhibiting gastric and pancreatic lipases,
causing approximately 30% fecal fat excretion
Prescribed 3 times a day at a dosage of 120 mg to be taken with meals
A lower-dose formulation containing 60 mg per capsule is available over
the counter and sold under the brand name Alli
Side : bloating, flatulence, flatus with discharge, and fecal incontinence
reduces the absorption of fat-soluble vitamins(A, D, E, K), a multivitamin
supplement is advised when treating with this agent
Lorcaserin(Belviq)
Approved by the FDA in 2012 for long-term weight management
Selective serotonin 2c receptor agonist
decreases food consumptionand promotes satiety by selectively
activating the 5HT-2c receptor on anorexigenic POMC neurons located in
the hypothalamus
daily dose of 10 mg twice a day
Side effects : headaches, dizziness, and nausea, hypoglycemia(reduction
in diabetic medication dosage may be needed)
PHENTERMINE/TOPIRAMATE (QSYMIA)
Approved by the FDA in 2012
Phentermine increases norepinephrine in the hypothalamus, enhancing POMC neuron pathway signaling to increase alpha-MSH, which binds to melanocortin 4 receptor and suppresses appetite
The exactmechanism of action for weight loss with topiramate is not known
4 dosages:
3.75/23mg (starting dose)
7.5/46mg (treatment dose)
11.25/69mg
15/92 mg (maximumdose
a stepwise approach, starting at 3.75/23 mg once daily for 2 weeks before increasing to the recommended dose of 7.5/46 mg once daily
Further titration to a maximum dose of 15/92 mg once daily may be considered for individuals who do not achieve 3%weight loss after 12 weeks.
If 5% weight loss is not achieved after 12 weeks at 15/92mg per day, then phentermine/topiramate ER dose should be gradually reduced for discontinuation
Qsymia(contd)
Side effects: paresthesias,dizziness, dysgeusia, and dry mouth
Inform women of reproductive age about the increased risk of congenital
malformation during the first trimester of pregnancy
Liraglutide(Saxenda)
Glucagon-like peptide-1 (GLP-1) agonist
cause glucose-dependent insulin secretion from pancreatic beta cells to
lower glucose levels, suppression of glucagon secretion, and slowing of
gastric emptying
FDA approved in 2014
Dose up to 3.0 mg once daily
Side effects: nausea, vomiting, hypoglycemia and diarrhea, increased
lipase, abdominal pain,
NALTREXONE /BUPROPION
(CONTRAVE
FDA approved in 2014
Given the known individual effects of naltrexone and bupropion on
addiction (alcohol and smoking, respectively), a fixed combination was
hypothesized to induce weight loss through sustained modulation of
central nervous system reward pathways
Gelesis
Each capsule contains thousands of proprietary, biocompatible hydrogel particles synthesized with starting materials that are Generally Recognized as Safe by the FDA
capsules are taken before a meal with water, after which the small particles within the capsules hydrate and expand in the stomach and small intestine,triggering several important satiety and glycemic control mechanisms
built-in safety features:
(a) the volume it creates is limited by the amount of water consumed
(b) the hydrated particles, which are 2 mm in size, do not cluster or stick together and have similar elasticity (rigidity) as ingested food
(c) the particles partially degrade in the colon, releasing absorbed water
Pilot Human Study initiation is planned in 2019
Bariatric Surgery at Mercy Medical
Center
Numbers
Sleeve gastrectomy :113
Gastric Bypass: 22
Before325.3
LBS
After175 LBS
SUCCESS STORIES
Before After
Program Start Date
December 26, 2016
Program Start Weight –
325.3 lbs Starting BMI –
54.13
Sleeve Gastrectomy
May 30, 2017
Current Weight – 175 lbs
Current BMI – 28
Total Weight Loss 150.3 lbs
Starting Pant Size – 26
Current Pant Size – 10/12
Before258
LBS
After
150 LBS
SUCCESS STORIESProgram Start Date
July 10, 2017
Program Start Weight - 258 lbs
Starting BMI – 43.6
Sleeve Gastrectomy
November 28, 2017
Current Weight – 150 lbs
Current BMI – 25.08
Total Weight Loss 108 lbs
Starting Pant Size – 18/20
Current Pant Size – 6/8
Before442 LBS
After325.2 LBS
SUCCESS STORIES
Before After
Program Start Date
September 29, 2016
Program Start Weight - 442 lbs
Starting BMI – 56.75
Sleeve Gastrectomy
April 18, 2017
Current Weight – 325.2 lbs
Current BMI – 40.65
Total Weight Loss 116.8 lbs
Before
320 LBS
After135 LBS
Success Stories
Program Start Date
March 30, 2017
Program Start Weight - 320 lbs
Starting BMI – 54.08
Sleeve Gastrectomy
September 20, 2017
Current Weight – 135 lbs
Current BMI – 23.19
Total Weight Loss 185 lbs