Pharmacologic and Surgical Management of OBESITY in Primary Care

1. Pharmacologic and Surgical Managementof OBESITY in Primary Care Rey Vivo, MD Assistant Professor of Medicine Texas Tech University Health Sciences Center

2. Which of the following is/are true regarding obesity? A. Obesity is generally defined as BMI > 30 B. Last year, only 4 states remain to have obesity prevalence < 20% C. All obese patients, without exception, need counseling for TLC D. Pharmacologic treatment lack long-term safety data E. Bariatric surgery, while effective, may have multiple GI, nutritional and metabolic complications What is the best answer?

3. Define overweight and obesity Epidemiology trends Contributing factors Health consequences ACP Management Guidelines Pharmacologic Surgical Objectives

4. Definitions • Body Mass Index (BMI) • Formula: weight (kg) / [height (m)]2 • Formula: weight (lb) / [height (in)]2 x 703 • Caveats: • Women • Elderly • Highly-trained athletes • Abdominal fat

5. In 2006, the following states had the lowest prevalence of obesity (< 20%) except: A. Connecticut B. Massachusetts C. West Virginia D. Hawaii E. Colorado What is the best answer?

6. Epidemiology:Obesity Trend 1990 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% Source: Centers for Disease Control and Prevention

7. Epidemiology:Obesity Trend 1998 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% Source: Centers for Disease Control and Prevention

8. Epidemiology:Obesity Trend 2006 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% Source: Centers for Disease Control and Prevention

9. The following medical conditions may cause obesityexcept: A. Cushing’s syndrome B. Hypothyroidism C. PCOS D. Growth hormone excess What is the best answer?

10. Energy imbalance: calories consumed vs. used Environment Genetics Medical conditions Endocrine: Hypercortisolism, hypothyroidism, growth hormone deficiency, pituitary/ hypothalamic disorders Genetic: Down, Prader-Willi syndromes Medications: Chronic glucocorticoids, neuropsychotropic medications (atypical antipsychotics e.g. clozapine, TCAs e.g. clomipramine) Contributing Factors

11. In the IM Boards, obesity if a risk factor for which 2 medical conditions? A. Osteoarthritis and Uterine CA B. Osteoarthritis and Osteoporosis C. Uterine CA and Osteoporosis D. Uterine Ca and Sleep Apnea “Classic” ABIM Question

12. Hypertension Metabolic syndrome Osteoarthritis Dyslipidemia Type 2 diabetes Coronary heart disease Stroke Gallbladder disease Sleep apnea and respiratory problems Some cancers (endometrial, breast, and colon) Health Consequences

13. ACP GuidelinesPharmacologic and Surgical Management

14. ALL obese patients should be counseled on therapeutic lifestyle changes such as: Diet Exercise Individualized weight and health goals Recommendation # 1

15. ALGORITHM FOR MANAGING OBESITY Snow V, et al. Ann Intern Med.2005;142:525-531.

16. Pharmacologic treatment can be offered to obese patients who have failed TLC. (1) Side effects, (2) lack of long-term safety data and (3) temporary nature of weight loss needs to be discussed. Recommendation # 2

17. Adjunctive drug therapy options include: Sibutramine Orlistat Phentermine Diethylpropion Fluoxetine Bupropion Choice will depend of side effects and patient’s tolerance Recommendation # 3

18. Snow V, et al. Ann Intern Med.2005;142:525-531.

19. Myocardial Infarction Induced by Appetite Suppressants in MalaysiaThe authors report on two otherwise healthy young women who had myocardial infarction with acute ST-segment elevation associated with the use of phentermine and sibutramine.

20. Surgery should be considered as an option for patients with BMI > 40 who failed TLC (with or without adjunctive drugs) and who present with obesity-related comorbid conditions. Long-term side effects (e.g. possible need for re-operation, gall bladder disease and malabsorption) should be discussed. Recommendation # 4

21. Types of Bariatric Surgery Vertical banded gastroplasty Biliopancreatic diversion Figures from utdol.com

22. Roux-en-Y gastric bypass Figures from utdol.com

23. Bariatric Surgery Complications:Top 10 Abell TL and Minocha A. Am J Med Sci. 2006;331:214-218.

24. Macronutrient Protein-calorie malnutrition; S/Sx: Excessive weight loss (either beyond pre-determined goals or too rapidly) Severe diarrhea and/or steatorrhea Low or diminishing visceral protein markers (i.e. albumin and prealbumin) Hyperphagia Muscle wasting (marasmus) Edema (kwashiorkor) Fat Malabsorption Nutritional Complications Malinowski SS. Am J Med Sci. 2006;331:219-225.

25. Micronutrient Vitamin B12 Iron Folate Calcium Thiamine Fat-soluble vitamins Nutritional Complications

26. Cholelithiasis From post-surgical weight loss not the surgery About 50% had sludge, which may lead to cholesterol stones Ursodiol x 6 months post-bypass effective in reduction of events Laparoscopic cholecystectomy usually safe and effective in symptomatic uncomplicated cholelithiasis Surgical treatment of choledocholithiasis may be more complicated due to difficult access to biliary tree by ERCP Another Complication

27. Patient should be referred to high-volume centers with surgeons experienced in bariatric surgery. Recommendation # 5

28. Obesity is generally defined as BMI > 30 Prevalence is growing; last year, only 4 states remain to have obesity prevalence < 20% All obese patients, without exception, need counseling for TLC (i.e. diet, exercise, individual goals) Pharmacologic treatment lack long-term safety data Bariatric surgery, while effective, may have multiple GI, nutritional and metabolic complications Take Home Points MANAGEMENT MUST BE INDIVIDUALIZED AND THOROUGHLY DISCUSSED WITH A MULTI-DISCIPLINARY TEAM.

29. Thank you and Keep fit!