1 / 42

Hot Topics in Obesity Treatment

Hot Topics in Obesity Treatment. Prevalence of Overweight and Obesity Among US Adults. (BMI  25.0). (BMI 25.0-29.9). (BMI  30.0). Up 100% in 20 years. NHANES II* 1976-1980 (n=11,207). NHANES † 1999-2000 (n=3601). NHANES III 1988-1994 (n=14,468).

briana
Download Presentation

Hot Topics in Obesity Treatment

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Hot Topics in Obesity Treatment

  2. Prevalence of Overweight and Obesity Among US Adults (BMI 25.0) (BMI 25.0-29.9) (BMI 30.0) Up 100% in 20 years NHANES II*1976-1980(n=11,207) NHANES†1999-2000(n=3601) NHANES III1988-1994(n=14,468) NHANES=National Health and Nutrition Examination Survey. *Age-adjusted by the direct method to the year 2000; US Bureau of the Census estimates using the age groups 20-34, 35-44, 45-54, 55-64, and 65-74 years †Flegal KM et al. JAMA. 2002;288:1723-1727.

  3. Binge Eating • Could there be a survival advantage to being able to binge or eat more in an environment with limited food?

  4. Lateral Hypothalamic area Pituitary Forebrain Adrenals Paraventricular Nucleus Feeding behavior Metabolic status save calories burn calories Y1-receptor MC4R Insulin Pancreas POMC MSH NPY Leptin Adipose tissue Ghrelin Stomach PYY Intestines

  5. Binge and MC4R Gene • Two articles in the NEJM March 2003 • Branson: 5.1% of obese had MC4R gene mutations • Farooqi: 5.8 % of obese had MC4R gene mutations • All mutation carriers reported binge eating

  6. Binge Eating • 469 morbid obese Caucasian patients • 79% female • Found 24 pts (5.1%) with a mutation of the MC4R • Basically a defective receptor • All 24 of these pts (100%) had binge eating • Only 14% of matched controls had binging NEJM 348:12, 2003.

  7. Binge Eating • 500 morbid obese children • Found 29 pts (5.8%) with a mutation of the MC4R • Basically a defective receptor • All 29 of these patients had “hyperphagia” • Compared to unaffected siblings they ate three times as much food at a single meal • Meal size corrected for lean body mass NEJM 348:12, 2003.

  8. Sibling With Mutation Sibling Without Mutation Homozygous Mutation in Melanocortin-4 Receptor Gene Farooqi IS et al. N Engl J Med. 2003;348:1085-1095.

  9. MC4R Mutations • Mutations carriers were: • Severely obese • Increased lean mass • Increased linear growth • Severe hyper-insulinemia • Homozygotes were more severely effected than heterozygotes

  10. Binge Eating Disorder Definition of a Binge Episode • Eating an amount of food that is definitely larger than most people would eat in similar circumstances during a similar period of time (eg, 2x a normal portion in 2 hours) • A sense of lack of control during the episodes • Sense of inability to stop or control eating • Marked distress about the binge eating • Women yes, men often not • Binge eating is a provisional DSM code at this time

  11. Secondary Binge Criteria • Eat alone (closet eating) • Eat when not hungry • Eat fast • Eats until uncomfortably full • Feeling of guilt or un-happiness after eating • Loose criteria different for men and women

  12. Questions for the Clinician to Ask Patients Who Might Have Binge Eating Disorder • Do you ever have episodes of eating where you feel out of control or that you just could not stop yourself? • Do you ever eat large portions of food that would clearly be larger portions that other persons might eat in a similar circumstance?

  13. Diagnostic Criteria for Bulimia Nervosa (BN) • Recurrent episodes of binge eating with loss of control • Recurrent inappropriate compensatory behavior to prevent weight gain • Binge eating and inappropriate compensatory behavior both occur, on average, at least twice a week for 3 months • Self-evaluation is unduly influenced by body shape and weight

  14. Prevalence of BED in Community Samples • BED is found in ~ 2% to 3% of adults • About half are obese Bruce B, Agras WS. Int J Eat Disord. 1992;12:365-373. Spitzer RL et al. Int J Eat Disord. 1992;11:191-203.

  15. Prevalence of BED in Clinical Samples • BED in obese treatment seekers • ~ 7.6% to 18.8% (rigorously defined) • ~ 20% to 40% (broadly defined) • BED in Overeaters Anonymous: ~ 70% • BED in bariatric surgery seekers: ~ 25% to 50% Stunkard AJ. In: Handbook of Obesity Treatment. 2002. Wadden TA et al. Surg Clin N Am. 2001;81:1001-1014. Williamson DA, Martin CK. Eat Weight Disord. 1999;4:103-114.

  16. BED and Depression Yanovski SZ, et al. Am J Psychiatry. 1993; 150:1472-1479.

  17. % of Subjects Binge eaters 40 Nonbingers 30 20 10 0 23-24 34-42 24-25 31-34 30-31 25-27 27-28 28-30 BMI Category Binge Eating and Overweight Telch CF et al. Int J Eat Disord. 1988;7:115-119.

  18. 0 Placebo Fluoxetine hydrochloride 20 mg/d Fluoxetine hydrochloride 60 mg/d 20 Median Change, % of Episodes 40 60 80 0 1 2 3 4 5 6 7 8 Study Week Frequency of Binge Eating in BN Fluoxetine Bulimia Nervosa Collaborative Study Group. Arch Gen Psychiatry. 1992;49:139-147.

  19. 7 6.1 Placebo 6 Fluoxetine 6.0 5 4 Mean Binges/week 3 2.7 2 1.8 1 0 0 1 2 3 4 5 6 Weeks Fluoxetine in BED Mean Binges/Week P = 0.03 Arnold LM et al. J Clin Psychiatry. 2002;63:1023-1028.

  20. Sibutramine in BED • Placebo-controlled, randomized, double-blind trial • 15 mg/d • 4-week placebo run-in; 6-month double-blind treatment • Placebo run-in n = 549 • Randomized n = 304 • Completed n = 189 • Baseline values determined after placebo run-in • Outcome measures: • Binge frequency and weight • A significant difference from placebo was achieved for both outcomes Wilfley DE et al. Presented at: the Eating Disorders Research Society Annual Meeting; Charleston, South Carolina; November 20-22, 2002.

  21. Sibutramine in BED Binge Days Per Week Weight Change Wilfley DE et al. Presented at: the Eating Disorders Research Society Annual Meeting; Charleston, South Carolina; November 20-22, 2002.

  22. Intermittent Drug Therapy

  23. 0 -4 Continuous Placebo -8 -12 -16 Weight Loss (lbs) -20 ContinuousPhentermine -24 Alternate Phentermine and Placebo -28 -32 0 4 8 12 16 20 24 28 32 36 Time (weeks) Effect of Continuous and Intermittent Phentermine Therapy on Body Weight Munro JF et al. Brit Med J 1:352, 1968.

  24. Effect of Continuous vs Intermittent Sibutramine Therapy on Body Weight 0 Placebo Intermittent sibutramine Continuous sibutramine -2 -4 Body Weight Change (kg) -6 -8 Run-in period -10 0 4 8 12 16 20 24 28 32 36 40 44 48 Time (wk) Sibutramine dose = 15 mg/d Wirth and Krause. JAMA 2001;286:1331.

  25. Pharmacologic and Surgical Management of Obesity in Primary Care:A Clinical Practice Guideline from the ACP Ann Intern Med 2005;142:525-531.

  26. Medications Used for Weight Loss • Phentermine* • Diethylpropion* • Sibutramine# • Orlistat# * Approved by the FDA for short term weight loss # Approved by the FDA for weight loss and weight maintenance

  27. “Off-label” Use of Medications for Weight Loss • Bupropion • Fluoxetine • Sertraline • Topiramate • Zonisamide

  28. Coverage of Weight Loss Medications • Typically not covered as a general rule • Although see 30% to 40% coverage • Typically covered medical conditions that get coverage of weight loss medications • Morbid obesity: • With the threat of bariatric surgery • Diabetes • Patients with BMI of ≥ 35 with co-morbid condition • Metabolic syndrome

  29. Paperwork: Billing Codes • Very rarely covered by health insurances • Obesity – 278.00 • Usually paid billing codes • Morbid obesity – 278.01 • Dysmetabolic Syndrome – 277.7 • Impaired fasting glucose – 790.21 • Impaired GTT – 790.22

  30. ACP Guidelines • 5 recommendations based on the evidence report and accompanying background papers developed by the Southern California Evidence-Based Practice Center • The ACP recommends all clinicians refer to these guidelines as part of an overall strategy for managing overweight and obese patients • Overall strategy should always include appropriate diet and exercise • Target audience is patients with BMIs of above 30

  31. ACP GuidelinesRecommendation #1 • Clinicians should counsel all patients with a BMI above 30 on lifestyle and behavior modifications such as appropriate diet and exercise • Patient goals should be individually determined

  32. ACP GuidelinesRecommendation #2 • Pharmacologic therapy can be offered to patients who have failed diet and exercise alone • Doctor-patient discussion of side effects, long term safety data, and temporary nature of weight loss achieved with medications should occur before medication initiation

  33. ACP GuidelinesRecommendation #3 • Medication choices for the obese patient include: sibutramine, orlistat, phentermine, diethylpropion, fluoxetine and bupropion • The choice of drug should be dependent on the side effect profile and the patients tolerance of the side effects

  34. ACP GuidelinesRecommendation #4 • Surgery should be considered as a treatment option for patients with a BMI over 40 who: • Instituted but failed an adequate exercise and diet program (with or without adjunctive drug therapy) AND • Present with obesity-related comorbid conditions such as hypertension, impaired glucose tolerance, diabetes mellitus, hyperlipidemia and obstructive sleep apnea • Doctor-patient discussion of surgery should include long term side effects

  35. ACP GuidelinesRecommendation #5 • Patients should be referred to high-volume centers with surgeons experienced in bariatric surgery

  36. Bariatric Surgery

  37. Recommendations for Patient Selection • Between ages 18 and 50 • Stable preoperative weight for 3-5 years • Smoking cessation for at least 6 weeks • Those with psychiatric history require careful assessment • Tests to predict success of surgery: • Personality factors • Eating habits • Motivation Grace DM. Gastroenterol Clin North Am. 1987;16:399.

  38. Types of Surgery: Gastric Bypass • Roux-en-Y gastric bypass is the most popular in the US • Pouch can be created with staples or complete division • Long-term weight loss of 50% of excess body weight • Moving Roux limbs distally creates more rapid weight loss • Malabsorption problems may be exacerbated

  39. Types of Surgery: Gastroplasty • Vertical banded gastroplasty now the preferred type of gastroplasty • Less enlargement over time • Produces weight loss, but usually less than gastric bypass

  40. Types of Surgery: Gastric Banding • Problems with original gastric band • Pouch too large or small • Adjustable gastric band developed in the 1980s • Controls restriction by injection/withdrawal of saline • May be performed laparoscopically

  41. Mechanisms • Operations dramatically restrict gastric size, reducing nutritional intake • Some types of surgery decrease the absorption efficiency of nutrients • Roux-en-Y gastric bypass • Biliopancreatic diversion (BPD) • Malabsorption procedures create a greater risk for nutritional deficiencies

  42. Iron deficiency Vitamin B12 deficiency Folic Acid deficiency Dehydration Vitamin A deficiency Electrolyte deficiency Protein deficiency Hyperparathyroidism Follow up of nutritional and metabolic problems after bariatric surgery K. Fujioka Diabetes Care 28:481-484,2005 Nausea Vomiting Abdominal pain Constipation Marginal ulceration Gallstones Bleeding ulcer Obstruction of the stomach outlet Side Effects & Complications 1 in 200-300 patients in the US die from bariatric surgery Shikora SA. Nutrition in Clinical Practice. 2000;15:13. www.mayoclinic.com. Surgery for obesity: What is it and is it for you?. Accessed February 15, 2005.

More Related