Pharmacologic and Surgical Management of OBESITY in Primary Care

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Pharmacologic and Surgical Managementof OBESITY
in Primary Care

• Rey Vivo, MD
• Assistant Professor of Medicine
• Texas Tech University Health Sciences Center

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What is the best answer?

• Which of the following is/are true regarding
  obesity?
• A. Obesity is generally defined as BMI gt 30
• B. Last year, only 4 states remain to have
  obesity
• prevalence lt 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

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Objectives

• Define overweight and obesity
• Epidemiology trends
• Contributing factors
• Health consequences
• ACP Management Guidelines
• Pharmacologic
• Surgical

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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

BMI Weight status
lt 18.5 Underweight
18.5 - 24.9 Normal
25 29.9 Overweight
30 39.9 Obese
gt 40 Extremely obese
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What is the best answer?

• In 2006, the following states had the lowest
  prevalence of obesity (lt 20) except
• A. Connecticut
• B. Massachusetts
• C. West Virginia
• D. Hawaii
• E. Colorado

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EpidemiologyObesity Trend 1990
No Data lt10 1014
1519 2024 2529
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Source Centers for Disease Control and
Prevention
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EpidemiologyObesity Trend 1998
No Data lt10 1014
1519 2024 2529
30
Source Centers for Disease Control and
Prevention
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EpidemiologyObesity Trend 2006
No Data lt10 1014
1519 2024 2529
30
Source Centers for Disease Control and
Prevention
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What is the best answer?

• The following medical conditions may cause
  obesity except
• A. Cushings syndrome
• B. Hypothyroidism
• C. PCOS
• D. Growth hormone excess

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Contributing Factors

• 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)

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Classic ABIM Question

• 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

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Health Consequences

• 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)

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ACP GuidelinesPharmacologic and Surgical
Management
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Recommendation 1

• ALL obese patients should be counseled on
  therapeutic lifestyle changes such as
• Diet
• Exercise
• Individualized weight and health goals

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ALGORITHM FOR MANAGING OBESITY Snow V, et al. Ann
Intern Med.2005142525-531.
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Recommendation 2

• 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.

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Recommendation 3

• Adjunctive drug therapy options include
• Sibutramine
• Orlistat
• Phentermine
• Diethylpropion
• Fluoxetine
• Bupropion
• Choice will depend of side effects and patients
  tolerance

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Snow V, et al. Ann Intern Med.2005142525-531.
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                                     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.
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Recommendation 4

• Surgery should be considered as an option for
  patients with BMI gt 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.

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Types of Bariatric Surgery
Restrictive Vertical banded gastroplasty
Gastric banding
Malabsorptive Long-limb gastric bypass
Biliopancreatic diversion
Biliopancreatic diversion with duodenal switch
Restrictive and Malabsorptive Roux-en-Y gastric bypass
Vertical banded gastroplasty
Biliopancreatic diversion
Figures from utdol.com
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Roux-en-Y gastric bypass
Figures from utdol.com
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Bariatric Surgery ComplicationsTop 10
No. Complication Restrictive Combination
1. Dumping (early and late) 0.3 14.6
2. Vitamin/mineral deficiency 1.6 11.0
3. Vomiting/nausea 8.5 2.6
4. Staple line fracture 1.5 6.0
5. Infection 3.1 5.3
6. Stenosis/bowel obstruction 2.2 2.7
7. Ulceration 1.2 1.2
8. Bleeding 0.5 0.9
9. Splenic injury 0.2 0.8
10. Death (peripoeratively) 0.1 0.4
Abell TL and Minocha A. Am J Med Sci.
2006331214-218.
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Nutritional Complications

• 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

Malinowski SS. Am J Med Sci. 2006331219-225.
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Nutritional Complications

• Micronutrient
• Vitamin B12
• Iron
• Folate
• Calcium
• Thiamine
• Fat-soluble vitamins

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Another Complication

• 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

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Recommendation 5

• Patient should be referred to high-volume
  centers with surgeons experienced in bariatric
  surgery.

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Take Home Points

• Obesity is generally defined as BMI gt 30
• Prevalence is growing last year, only 4 states
  remain to have obesity prevalence lt 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

MANAGEMENT MUST BE INDIVIDUALIZED AND
THOROUGHLY DISCUSSED WITH A MULTI-DISCIPLINARY
TEAM.
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Thank you and Keep fit!