Medical Management of Obesity

1. Medical Management of Obesity Jeanne M. Ferrante, MD, MPH Associate Professor Robert Wood Johnson Medical School Family Medicine and Community Health Nirav Rana, MD Bariatric Surgeon Bariatrx

2. Disclosures Dr. Ferrante has received grant/research support from Horizon Health Innovations within the past 12 months. Dr. Rana has nothing to disclose relevant to this presentation.

3. Objectives • Identify patients who would benefit from surgical intervention for the treatment of obesity and its associated co-morbid conditions. • Discuss the clinical benefits of bariatric surgery • Discuss the long term management of patients after bariatric surgery

4. Trends in Obesity Prevalence 1976-2010

6. Determining Treatment

7. Treatment Options • Correct underlying metabolic problems • Diet, exercise, behavioral therapy • Medications • Optimize current medication • Anti-obesity medications • Bariatric Surgery

8. Diet and Exercise • Low calorie diet:  500-1000 kcal/d • Women: 1200-1500 kcal/d • Men: 1500-1800 kcal/d • Very low calorie diet: 800 calories or less • 3-6 months (BMI > 50) • Before surgery or long term wt-loss program • Daily aerobic exercise ~ 60 minutes • Weight training after aerobic goals met

9. Low-carb vs. Low-fat diet • Doesn’t matter what kind of diet • Weight loss similar (11% at 6 and 12 months, 7% at 24 months) • Decrease in blood pressures similar • Decrease LDL and TG similar • Increase HDL (20%) in low carb • Weight loss maintenance • low glycemic index, higher protein diet

10. Low Glycemic Index http://www.the-gi-diet.org/lowgifoods/ Fruits- cherries, plums, grapefruit, peaches, prunes, apples, pears, grapes, oranges, strawberries- avoid watermelon Most vegetables except beets, pumpkin, parsnips Wheat pasta, egg fettuccini, spaghetti, brown rice, white long grain rice Avoid white bread, bagel, french baguette

12. Behavioral Modification • Self-monitoring • Goal setting • Stimulus control • activities, cues, circumstances, and practices that favor nonmeal eating and snacking • Eat most meals at home • Drink 500 ml water before each meal • Optimal sleep (7-8 hours)

13. Preventive Counseling Codes • Obesity screening and and dietary counseling (V65.3) • Exercise counseling (V65.41) • CPT • 99401 (15 min) • 99402 (30 min) • 99403 (45 min) • 99404 (60 min)

14. Medicare Coverage for Obesity • Intensive Behavioral Therapy (G0447) • Primary care physician or NP/PA/certified clinical nurse specialist- face-face x 15 mins • Up to 22 visits over 12 months • Every 1 week (Month 1), every 2 weeks (Months 2-6) • If loses 3 kg, continue every 4 weeks (Months 7-12) If not, can reassess after 6 monhts • 5A’s: Assess, Advise, Agree, Assist, Arrange • Not separately payable with another encounter

15. Medicare Codes

17. Medications • Optimize current medications • Anti-obesity drugs • Short term: benzphetamine, diethylproprion, phendimetrazine, phentermine • Long term • Inhibits fat absorption: orlistat (Xenical, Alli) • Decrease appetite • phentermine/topiramate (Qsymia) • lorcaserin (Belviq)

18. Optimize Medications

21. Medications • Orlistat (Xenical, Alli) • Lipase inhibitor: inhibits fat absorption • 120 mg tid during or up to 1 hour after meal • Side effects: flatulence, oily stool, diarrhea, and stool incontinence • Reduces absorption of fat-soluble vitamins and beta-carotene: take vitamins 2 hours before or 1 hour after meal

22. Medications • Phentermine-topiramate (Qsymia) • Low dose: 7.5 mg/46 mg  8.0% weight loss • High dose: 15 mg/92 mg  10.5% weight loss • Side effects: increased heart rate, palpitations, drowsiness, paresthesias, memory loss, confusion • Contraindicated in pregnancy (orofacial cleft) and recent/unstable CAD or CVD • Risk evaluation and mitigation strategy (REMS)

23. Medications • Lorcaserin (Belviq) • 10 mg bid • selectively activates 5-HT2C receptors on anorexigenicneurons in the hypothalamus  decreases eating and promotes satiety • 4.5% - 5.8% weight loss • Side effects: headache, dizziness, fatigue, drowsiness, nausea, dry mouth, constipation • Contraindicated pregnancy, caution CHF

24. Bariatric Surgery

25. Number of Bariatric Surgeries Performed American Society for Metabolic and Bariatric Surgery

26. Indications • BMI >40 kg/m2 or BMI >35 kg/m2 with an associated medical comorbidity worsened by obesity • Failed dietary therapy • Psychiatrically stable without alcohol dependence or illegal drug use • Knowledgeable about the operation and its sequela • Motivated individual • Medical problems not precluding probable survival from surgery

27. Obesity Related Conditions • Diabetes • Hypertension • Hyperlipidemia • Respiratory disease • Sleep apnea • Depression • Menstrual irregularity • Cardiovascular disease • Urinary stress incontinence • Asthma/pulmonary disorder • Gastroesophageal reflux disease (GERD) • Degenerative joint disease (DJD) • Congestive heart failure • Gallstones • Coronary heart disease • Stroke • Osteoarthritis • Cancer • Amenorrhea • Polycystic ovary syndrome • Infertility • Dysmenorrhea

28. Preop Evaluation • Nutritionist visits • Psychological evaluation • Exercise Physiology evaluation • EGD with biopsies for H. pylori • UGI series • IVC filter placement • Cardiopulmonary evaluation • Routine bloodwork • Vitamin levels

29. Adjustable Gastric Band • Silicone band • Encircles proximal stomach • Purely restrictive procedure

31. The Foregut Theory Exclusion of Duodenum from transit of nutrients prevents secretion of signal that promotes insulin resistance and DM type 2 Rubino F. Annals of Surgery • Vol 244, Nov 2006

32. Sleeve Gastrectomy • A gastric tube of 60 to 120mL is created • Induces weight loss by 2 mechanisms:1) Mechanical restriction2) Hormonal modification

33. Sleeve Gastrectomy Long Term results Himpens J. Ann Surg 252: 319–324 2010

34. Bypass versus Band • Bypass 90 80 70 60 50 40 30 20 10 • Band Resolution % DM HTN Dyslipidemia OSA Preoperative Morbidity Tice J. Am J Med. Vol 121, 10. 2008

35. Comparison of Bariatric Surgery Meta Analysis Buchwald, H. JAMA 2004

36. Bariatric Surgery versus Intensive Medical Therapy Change in BMI Intensive medical therapy Gastric Sleeve Gastric Bypass Schauer P, NEJM 2012

37. Long-Term Management after Bariatric Surgery

38. Long-term complications Short-term complications: stomal stenosis, incisional hernia, marginal ulcer, constipation Cholelithiasis Dumping syndrome: abdominal pain, N/V, diarrhea, tachycardia, flushing, dizziness Vomiting/GERD from pouch distention

39. Long-term complications Nutritional deficiencies: Calcium/Vit D, iron/folate, B vitamins, protein, potassium, Mg Panniculitis: antibiotics, skin hygiene, surgical excision Malabsorption of oral meds: avoid extended-release meds- use rapid release or oral solutions

40. Laboratory Testing

41. Diet Adequate protein: 80 g per day Eat slowly, chew thoroughly, cut foods into small pieces Avoid fluids 15-30 minutes before, during and after meals Avoid carbonated drinks/using straws Avoid very dry foods, breads, fibrous vegetables

42. Supplements

43. Pregnancy after Bariatric Surgery Wait 12-24 months Monitor nutritional status and deficiences Thoroughly evaluate GI symptoms Women with dumping syndrome may not tolerate 50-g glucose test Avoid NSAIDs during postpartum period Should not affect labor and delivery