8/13/18 - cdn.ymaws.com

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Susan Bowlin MSN, FNP-BC, ANCP-BC, CBN

TNP 30th Annual Conference

September 8, 2018

Overcoming ObesityCurrent Trends In Obesity Management

Disclosures

v None

Objectives

1. Discuss the current prevalence rates, definitions and treatment approaches of obesity in the United States.

2. Understand use of current FDA approved anti-obesity medications (AOMS).

3. Describe various bariatric surgeries and understand which patients to refer for evaluation.

THE DISEASE OF OBESITY

In the news…

Obesity extends duration of influenza A virus sheddingvAug 2, 2018

vObesity increases influenza disease severity & also extends by about 1.5 days how long the virus is shed.

Obesity increases risk of premature deathvJuly 2016

vHarvard study demonstrated that every 5 units higher BMI above 25 kg/m2 was associated with 31% higher risk of premature death.

According to the CDC in 2015-2016v39.8 % US population affected by obesityv93.3 million adults in USvEstimated cost (in 2008) was $147 billion

https://www.cdc.gov/obesity/data/adult.html [accessed 1 Aug 2018]accessed 7 Aug 2018)

Impact on Mortality

Obesity is associated with a 50-100% risk of premature death compared to healthy weight individuals.

vMedian survival rate is reduced by two-four years for individuals with BMI 30-35

vMedian survival rate is reduced by eight-to-ten years for individuals with BMI 40-45 which is comparable to smoking.

Office of the Surgeon General – U.S. Department of Health and Human Services. Overweight and obesity: health consequences. Accessed March 2012 from http://www.surgeongeneral.gov/topics/obesity/calltoaction/fact_consequences.html

https://www.cdc.gov/obesity/data/adult.html

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A look back in time…

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vIn 2000 starting to see the increasing prevalence of obesity. vBMI seen as a

major risk factor for DM.

vLow rates of addressing BMI with patients.

Evolving definition of obesity

Obesity is a chronic diseasevNOT a character flaw

vExcess weight or unhealthy weight

It has been proposed to call obesityvAdiposity-based chronic disease (ABCD)

Obesity Algorithm®. ©2017-2018 Obesity Medicine Association.

Definition of Obesity

“Obesity is defined as a chronic, relapsing, multi-factorial, neurobehavioral disease, wherein an increase in body fat promotes adipose tissue dysfunction and abnormal fat mass physical

forces, resulting in adverse metabolic, biomechanical, and psychosocial health

consequences.”


National Obesity Trends

National Health and Nutrition Examination Survey (NHANES), 2011-2014 data

GENDER AGE ETHNICITY

Texas Obesity Rates: 33.7% Ranking 8th/51

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25

30

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sity

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Gender

Obesity Rate by Gender (2012)

Men Women

28.5%

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10

15

20

25

30

35

40

45

Obe

sity

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Race

Obesity Rate by Race (2016)

White Black Latino

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10

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20

25

30

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40

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sity

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Age

Obesity Rate by Age Group (2016)

18 -25 26-44 45-64 65+

30.0%

29.2%

42.4%37.4%

23.9%

34.2%38.9%

30.0%

https://stateofobesity.org/states/tx [access on 1 Aug 2018]

https://stateofobesity.org/states/tx

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Effects of BMI and Smoking Status on Survival

Men 35-100 years old

N Engl J Med 2010; 362:855-857

Cost of Obesity

v Cost of obesity in the United States in 2000 was more than $117 billion

v Many insurance companies do not cover clinical or non-clinical weight-loss programs

Influences of Our Times

Patient

Portions

Family Schedule

Work Schedule

Business Meals

Eating Out

Distractions

CAN YOU RELATE?

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Convenience Crisis What Happened?

Home Cooking Daily Eating Out

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Convenient Abundance Adiposopathy Stress Cycle

Obesity, Adiposopathy, and Metabolic Disease

Chronic Stress

Behavior Changes, Endocrinopathies, and

ImmunopathiesIncreasing Body Fat

Worsening Adipose Tissue Function


Classifications

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BMI kg/m2 Classification

18.5-24.9 Heathy

25-29.9 Overweight/Pre-obese≥ 30 Obese

30.0-34.9 Class I Obesity

35-39.9 Class II Obesity≥ 40 Class III Obesity

Waist CircumferenceHealth Risk

Women Men

Low Risk < 31.5 inches < 37 inchesModerate Risk 34.5-35 inches 37-40 inchesHigh Risk 35 inches or more > 40

Height (ft/in)

4’9” 4’11” 5’1” 5’3” 5’5” 5’7” 5’9” 5’11” 6’1” 6’3”

154 33 31 29 27 26 24 23 22 20 19

165 36 33 31 29 28 26 24 23 22 21

176 38 36 33 31 29 28 26 25 23 22

187 40 38 35 33 31 29 28 26 25 24

198 43 40 37 35 33 31 29 28 26 25

209 45 42 40 37 35 33 31 29 28 26

220 48 44 42 39 37 35 33 31 29 28

231 50 47 44 41 39 36 34 32 31 29

243 52 49 46 43 40 38 36 34 32 30

254 55 51 48 45 42 40 38 35 34 32

265 57 53 50 47 44 42 39 37 35 33

276 59 56 52 49 46 43 41 39 37 35

287 62 58 54 51 48 45 42 40 38 36

298 64 60 56 53 50 47 44 42 39 37

309 67 62 58 55 51 48 46 43 41 39

320 69 64 60 57 53 50 47 45 42 40

HEIGHTHT

WEIGHT

Body Mass Index (BMI)

BMI: a universal measurementbut certainly not perfect

v Easily reproducible and consistentv Low costv Commonly usedv Problems:vDoes not account for muscle mass

vDoes not distinguish between gender, ethnic or racial considerations

2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults, Volume: 129, Issue: 25_suppl_2, Pages: S102-S138,

DOI: (10.1161/01.cir.0000437739.71477.ee)

ACC/AHA Obesity Guideline 2013

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Nutritional Intervention

Physical Activity

Pharmaco-therapy

Bariatric Procedures

Behavior Therapy

Motivational Interviewing

Management Decisions

Evaluation and Assessment

Obesity Algorithm

Obesity as a Disease

Data Collection


Bays HE, Seger, J, Primack C, Long J, Shah NN, Clark TW, McCarthy W. Obesity Algorithm, presented by the Obesity Medicine Association.

2017-2018. www.obesityalgorithm.org

Obesity Comorbidities

Comorbidities of Obesity

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Common manifestations reported by patients

v Insomnia/fatigue/daytime sleepinessv Mood changes/forgetfulness/depression

v Lack of interest in socializing & sexual activityv GERDv Pain: back, knee, hip, foot

v Stress Incontinencev Headachev Peripheral swelling

Physical Exam Findings

v Increased neck circumferencev Modified mallampati score of 3 or 4v Tonsillar hypertrophy/enlarged uvulav Peripheral edemav Cardiac dysrhythmiav HTN

Healthy Nutrition for Obesity

v Limit processed foods v Limit empty calories such as sweets, candy,

chipsv Beware of beverages with high

calories/sugar

v Encourage healthy proteins and fatsv Carbohydrates should be complex carbs

over simple carbs and look for low glycemic index foods

v High fiber foodsv Read the labels not the advertising!

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Factors that affect nutrition

v Individual food preferences, eating behaviors, meal plans and schedulesv Cultural background & traditionsv Availability of foodv Financial constraintsv Nutritional knowledgev Cooking skills and interestv Household makeup: cooking for 1?

Popular diets

v Ketogenicsv Paleov Atkinsv Mediterranean v Ornishv DASH (Dietary Approaches to Stop HTN)v Commercial Diet programs

vWeight Watcher’s

vNutrisystem

vJenny Craig

Hunger, appetite and satiety Tools/Questionnaires'

v STOP-Bang QuestionnairevScreen for sleep apnea

v QOL Indicatorv 2018 PAR-Q+ to establish exercise readiness

Sleep Apnea

In-office questionnaireSleep study referralvIn-home study

vIn-lab overnight studyvAHI (Apnea hypopnea index)

v5-15/hour = mild sleep apnea

v15-30/hour = moderate sleep apnea

v> 30/hour = severe sleep apnea

Consequences of untreated OSAvWorsening obesity

vCHF

vAF

vNocturnal dysrhythmiasvCVA

vHTN

vDM

vPulmonary HTN

Gender Specific Manifestations of Adiposopathy

WomenvHyperandrogenemia

vHirsutism

vAcne

vPolycystic ovarian syndromevMenstrual disorders

vInfertility

vGestational DM

vPreeclampsia

vThrombosis

MenvHypoandrogenemia

vHyperestorogenemia

vErectile dysfunction

vLow sperm countvInfertility

Obesity Algorithm 2017-2018 Obesity Medicine Association

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Increased risk of cancer

v Bladder cancerv Brain cancerv Breast cancer (post-menopausal)v Cervical cancerv Colon cancerv Endometiral/uterinev Kidney cancerv Leukemia

v Liver cancerv Multiple myelomav Non-Hodgkin lymphomav Pancreatic cancerv Prostate cancer (worsened prognosis, not

necessarily increased risk)v Stomach cancerv Thyroid cancer

New Patient Diet History

v Previous diet historyv Highest and lowest adult weightsv Co-morbiditiesv Eating disordersv Activity level: current and previousv Social:

tob/ETOH/drugs/employment/support system/home environment

v Medications/allergiesv Eating out

Eating History

Meals/SnacksvTiming

vFrequency

vNutritional content

vPortions

vWho prepares foods

BehaviorsvTriggers/nighttime eating/binge eating/readiness

for change

Record keeping

Physical activityvEnjoyment

vBarriers

vFrequency

vAccess

Lab Workup

Fasting CMPHemoglobin A1C

Fasting lipidsUric AcidThyroid panel

Vitamin D, B-1, B-12CBCIron studies

Based on H&P the patient may need additional testing such as:vCardiac stress test

vSleep study

vEcho

vBone density scan

Physical Activity

v Assess readinessv Able to walk?v Weight bearing exercise?v Ultimate goal is at least 150 minutes

weekly of moderate physical activity and resistance training for core strength

v Consider PT referralv Network with your local trainers and gyms

MOTIVATIONAL INTERVIEWING

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Pre-contemplationUnawareness of the problem

ContemplationThinking of change in the next 6 months

PreparationMaking plans to change now

ActionImplementation of change

RelapseRestart of unfavorable behavior

Stages of Change


Progress

Motivational Interviewing: Focus

Collaboration

• Working together to find and implement pragmatic solutions

• Not focusing on who is right and who is wrong

Evocation

• Drawing out the patient’s thoughts and ideas regarding solutions

• Not telling the patient what to do

Autonomy

• Empowering the patient to own the solution

• Not the authoritarian power of the clinician


All or nothing

Motivational Interviewing Techniques: 5A’s of Obesity Management

• Ask for permission to discuss body weight.• Explore readiness for change.Ask

• Assess BMI, waist circumference, and obesity stage.• Explore drivers and complications of excess weight.Assess

• Advise the patient about the health risks of obesity, the benefits of modest weight loss (i.e., 5-10 percent), the need for long-term strategy, and treatment options.

Advise

• Agree on realistic weight-loss expectations, targets, behavioral changes, and specific details of the treatment plan.Agree

• Assist in identifying and addressing barriers; provide resources; assist in finding and consulting with appropriate providers; arrange regular follow up.

Arrange/Assist


Multifactorial Approach to Therapy

Increased Physical Activity

Behavioral Therapy

Dietary Changes

• Diet recall• Previous Success• Build on

preferences

• Determine baseline• Discuss interests• Discuss barriers• Refer as needed

• Primary care• Dietitian• Counselor

HUNGERHORMONE REGULATION

Hunger Hormones

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Cardiovascular effects of Glucagon-like peptide 1 (GLP-1) receptor agonists - Scientific Figure on ResearchGate. Available from:https://www.researchgate.net/Pleitropic-effects-of-GLP-1-or-GLP-1R-agonists-Adapted-from-references-24_fig2_267740019 [accessed 5 Aug, 2018]

Hunger Hormones

Hormone Source Effect

CCK GI Tract Limits size of meal

Amylin, insulin, glucoagon Pancreas Limits size of meal

PYY Ileum/colon Postpones need to eat

GLP-1 Stomach Postpones need to eat

Oxcyntomodulin Stomach Postpones need to eat

Leptin Adipose tissue Lonterm regulation

Ghrelin Stomach Increase appetite

ANTI-OBESITYMEDICATIONS(AOMS)

Drugs That Increase Weightv TCAsv MOAIsv Paroxetinev Lithiumv Olanzapinev Clozapinev Risperidonev Carbamazepinev Valproatev Mirtazapinev Gabapentinv Amitriptylinev Valproic acidv Diphenhydramine

v Some beta blockersvPropranalolvAtenololvMetroprolol

v Older calcium channel blockersvNifedipinevAmlodipinevFelodepine

v Diabetes medicationsvMost insulinsvSulfonylueasvThiazolidinedionesvMeglitinides

v Some epilepsy medications

Anti-obesity Medications (AOBMs)Pharmacotherapy

Adipex

Belviq

Qysmia

ContraveSaxenda

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Food and Drug Administration (FDA) Principles

FDA-approved Anti-obesity Medication Indications:vPatients with obesity (e.g., BMI > 30kg/m2)

vPatients who are overweight (e.g., BMI > 27kg/m2) with presence of increased adiposity complications (e.g., type 2 diabetes mellitus, hypertension, dyslipidemia)*

vAnti-obesity medications are contraindicated in patients hypersensitive to the drugs

*If no clinical improvement (e.g., at least 4 - 5% loss of baseline body weight) after 12-16 weeks with one anti-obesity medication, then consider alternative anti-obesity medication or increasing anti-obesity medication dose (if applicable).



Drug Description Main Side Effects Drug InteractionsPhentermine Phentermine was approved in

1959, and is the oldest available approved anti-obesity drug. It is a DEA Schedule IV stimulant agent approved for short-term use (12 weeks). Some patients may lose about 5% of body weight.

Side effects include headache, high blood pressure, rapid or irregular heart rate, overstimulation, tremor, and insomnia. Should not use with overactive thyroid or uncontrolled high blood pressure or seizure disorder. Contraindicated in patients with history of cardiovascular disease, within 14 days of monoamine oxidase inhibitors, glaucoma, agitated states, drug abuse

Monoamine oxidase inhibitors, sympathomimetics, antidepressants, alcohol, adrenergic neuron blocking drugs, and some anesthetic agents

Orlistat Orlistat impairs digestion of dietary fat. Lower doses are approved over-the-counter. Some patients may lose about 5% of body weight.

Side effects include oily discharge with flatus from the rectum, especially after fatty foods. (May help with constipation.) May promote gallstones and kidney stones. Will need to take a multivitamin daily. Contraindicated in chronic malabsorption syndrome and cholestasis.

Cyclosporine, hormone contraceptives, seizure medications, thyroid hormones, warfarin

Lorcaserin Lorcaserin is a DEA Schedule IV agent that improves the sense of fullness. Some patients may lose 5 – 10% of body weight.

Lorcaserin is a generally well-tolerated drug, with headache, dizziness, fatigue, nausea, dry mouth, and constipation occurring more frequently compared to placebo. Warnings and Precautions include serotonin syndrome, heart failure, psychiatric disorders, and priapism.

Serotonergic (SSRI’s, SNRI’s, MAO inhibitors) or anti-dopaminergic medications, St John’s wort, triptans, bupropion, dextromethorphan, CYP 2D6 substrates

Anti-Obesity Drug Summary (All have contraindications for hypersensitivity and pregnancy)


Drug Description Main Side Effects Some Drug Interactions

Liraglutide Liraglutide is an injectable drug, that in lower doses (1.8 mg per day), is also used to lower blood sugar. Some patients may lose 5 – 10% of body weight with the higher dose of the liraglutide 3.0 mg per day, which is the dose approved for treatment of obesity.

Adverse reactions include nausea, hypoglycemia, diarrhea, constipation, vomiting, headache, decreased appetite, dyspepsia, fatigue dizziness, abdominal pain, increase lipase, and renal insufficiency. Contraindicated with personal of family history of medullary thyroid cancer or Type 2 Multiple Endocrine Neoplasia syndrome. Discontinue with suspected pancreatitis, gall bladder disease, or suicidal behavior and ideation.

May slow gastric emptying, which may impact absorption of concomitantly administered oral medication.

Naltrexone / bupropion

This is a combination of naltrexone (opioid antagonist used for addictions) and bupropion (used for depression and smoking cessation). Some patients may lose 5 - 10% of body weight.

Naltrexone / bupropion can cause nausea, constipation, diarrhea, and headache. The bupropion component is an antidepressant, and antidepressants can increase the risk of suicide thinking in children, adolescents, and young adults; monitor for suicidal thoughts and behaviors. Should not be used in patients with uncontrolled high blood pressure, seizure disorders, or drug/alcohol withdrawal.

Opioid pain medications, anti-seizure medications, MAO inhibitors, and possible drug interactions with other drugs.

Phentermine / topiramate

This is a combination of phentermine (anti-obesity drug) and topiramate (used to treat seizures and migraine headaches). This DEA Schedule IV drug is approved as a weight management pharmacotherapy. Some patients may lose 5 – 10% of body weight.

Phentermine / topiramate can cause tingling or numb feelings to extremities, abnormal taste, insomnia, constipation, and dry mouth. Should not be used in patients with glaucoma, uncontrolled high blood pressure, heart disease, or hyperthyroidism. Topiramate can cause birth defects. Therefore, phentermine / topiramate should not be started until a pregnancy test is negative, unless the woman is using acceptable contraception, and pregnancy tests should be done monthly during use.

Monoamine oxidase inhibitors. May alter oral contraceptive blood levels.

Anti-Obesity Drug Summary (All have contraindications for hypersensitivity and pregnancy)

Adipex(Phentermine 8, 15, 30 & 37.5 mg)DEA schedule IV

Advantagesv Genericv Inexpensivev Good for overeatersv Decreases cravings

Disadvantagesv Not good for meal skippersv Limited duration: 3 monthsv Side effect profile

vDo not use with known ischemic vascular disease or uncontrolled HTN

Dry mouth Tachycardia Insomnia

Common side effects

Qsymia(Phentermine HCL/Topiramate)DEA schedule IV

Weeks1-2

Weeks3-12+

Completion of the FDA-mandated REMS program is optional and not required prior to prescribing phentermine HCL/topiramate extended release. Implementation of a REMS program by clinicians and pharmacies is intended to provide appropriate safety information to females of reproductive potential.

Weeks 13-14

Weeks 15+

If dose escalation needed for >3% weight loss after 12 weeks

Write 2 prescriptions when initiating therapy

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Qsymia(Phentermine HCL/Topiramate)DEA schedule IV

Mechanism of action Targets pro-opiomelanocortin (POMC) neurons in hypothalamus decreasing appetite & cravings and increases satietySympathomimetic amine, increases GABA activity, carbonic anhydrase inhibitor

Pharmacokinetics Phentermine metabolized by liver & excreted by kidney Topiramate is excreted mainly by kidney

Side Effects Paresthesia, dizziness, change in taste, constipation, dry mouth

Fetal toxicity: cleft palate. Increased HR, may cause DUB but NOT an increased risk of pregnancy; OCP should NOT be discontinued if spotting occurs. Avoid alcohol as may potentiate CNS depressants; may potentiate ↓K+ of non-potassium sparing diuretics. Need to increase hydration, may ↑kidney stones.

Contraindications Pregnancy, glaucoma, MAOIs (within 14 days), hyperthyroidism

Monitoring Obtain negative pregnancy test before staring and monthlyPossible lab abn: ↓ glucose; ↑ creatinine; metabolic acidosis

Belviq (lorcaserin) 10 mg BIDBelviq XR 20 mg QDDEA schedule IV

Mechanism of action Serotonin 2C receptor agonist: reduces appetite via POMC neuron activation in the hypothalamus

Pharmacokinetics CYP2D6 metabolism: renal excretionCan be administered with or without food

Side Effects Headache, nausea, fatigue,dry mouth, constipationIncreased hypoglycemia with diabetesCan increase suicidal thoughts, consider using PQH-9 for screeningDecrease BP, HR, Total & LDL-C& fasting glucose

Contraindications Renal failure (eGFR<30ml/min)Pregnancy/breastfeedingOther 5HT drugs

Belviq (lorcaserin) 10 mg BIDBelviq XR 20 mg QDDEA schedule IV

Advantagesv Makes soda and sweets

taste badv Not stimulant or narcoticv Very tolerable, can be

used in older adults

Disadvantagesv Contraindicated in pregnancy &

breastfeedingv Caution with moderate renal impairment &

severe hepatic impairment

v Side effects:vInsomnia, fatigue, dizziness, dry mouth,

constipation, memoryv Serotonin syndrome

v Cognitive impairment

v Hypoglycemia in patients treated for DM (29%)

v Monitor glucose more frequently

v Valvular heart disease

Warnings

Saxenda (Liraglutide)

Mechanism of action GLP-1 agonist; POMC neuron activation (appetite control via the satiety center)Delays gastric emptying

Pharmcokinetics 98 % protein boundNo specific metabolizing organ (SC injection)5-6 % excreted in urine/feces

Side Effects Nausea, headache, vomiting, diarrhea, constipation, dizziness, dyspepsia, fatigue

Contraindications Personal or family history of medullary thyroid carcinoma (MTC); multiple endocrine neoplasia syndrome type 2 (MEN 2); acute pancreatitis; active gallbladder diseaseRoutine monitoring of serum calcitonin or thyroid ultrasound is of uncertain value.

Caution Possible hypoglycemia with concomitant sulfonylurea, consider lowering dose and check glucose more frequently; renal impairment may worsen usually in association with dehydration associated with N/V/D.Patients on Saxenda should be monitored for emergence or worsening of depression or suicidal thoughts.

L van Bloemendaal et al. J Endocrinol 2014;221:T1-T16

GLP-1 & Glucose metabolism Saxenda (Liraglutide 3 mg)

v No pregnancy or breastfeedingv No personal or family history ofvMedullary thyroid cancer (MTC)vMultiple endocrine syndrome type 2

(MEN 2)vPancreatitis

Week1

Week2

Week3

Week4

Week5

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Contrave(Naltrexone 8 mg/Bupropion 90 mg)

Mechanism of action Naltrexone is an opioid antagonistBuproprion is an antidepressant suppresses appetite & craving

Pharmacokinetics Inhibits neuronal uptake of dopamine & norepinephrine; activates POMC neurons in the hypothalamus leading to decreased appetite

Side Effects N&V, constipation, diarrhea, headache, dry mouth, insomnia

Contraindications Should NOT be administered with opiods or with other drugs metabolized by CYP2D6 (SSRIs, MAOIs, antipsychotics (Haldol, risperidone & thioridazine; beta blockers (metoprolol); type 1C antiarrhythmics (propafenone & flecainide)Do not take with uncontrolled HTN or history of seizuresAvoid use in individuals with eating disorders

Black Box Warning Suicidal behavior & ideation

Contrave(Bupropion 90 mg/Naltrexone 8 mg)

v Good with depressed, emotional eatingv No pregnancy, seizures, opiod use or eating

disordersv Nausea can be a factor, don’t accelerate

the dose titrationv Consider discontinuation if <5% weight loss

after 12 weeks

Week1

Week2

Week3

Week4

Anti-Obesity PharmacologyDual Benefits

Obesity along with: May consider:

Diabetes Saxenda

Migraines Qysmia

Depression Contrave

Smoking Contrave

Case studiesAOMS

Bariatric Surgery

Sleeve Gastrectomy Gastric Bypass

Who Qualifies for Surgery?

v BMI >40 OR BMI >35 with comorbiditiesv History of non surgical weight loss attempts

vNamed dietsvDiet pillsvCounting calories and exercising

v No psychological contraindicationsv NON SMOKER

vTobacco free x 3 months, nicotine free x 2 monthsv DEDICATED TO LIFESTYLE CHANGE

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Operations

v Restrictive-vLaparoscopic vertical sleeve gastrectomy (“the sleeve”)

v Restrictive and MalabsorptivevLaparoscopic Roux en Y gastric bypass (“gastric bypass”)

Laparoscopic Vertical Sleeve Gastrectomy

v Restrictive Procedurev Developed early 2000’sv NOT reversiblev 60-65% excess body

weight lossv ~1.5 hours

v Works byv Restricting meal size

v Hormonal mechanisms

v Decreased appetite

Laparoscopic Roux en Y Gastric Bypass

v Combination procedurev Long history (1960’s)v NOT (easily) reversiblev 65-75% excess body weight lossv ~2.5 - 3 hoursv Restricts meal sizev Hormonal mechanismsv Reduces appetitev Limits absorption

Duodenum

Pouch

Bypassed Stomach

Roux Limb

Risks- both procedures

v 0.1% risk of death (1 out of 1000)v 4% risk of serious complications

v Bleedingv Deep vein thrombosis (DVT)

v Pulmonary Embolism (PE)

v Wound infectionsv Incisional hernias

Hospital Course

Day of surgery: vOut of bed, walking around

vIV pain medication

vBariatric clear liquids

Post op day 1:vBariatric clear liquids

vOral pain medications

vHome on bariatric stage II diet

vMedications liquid or crushed for 1 month after surgery

Bariatric surgery diet

2 weeks pre op

v2 protein shakes per day and 1 reasonable meal

Post op day 1

vBariatric Stage I (clear liquids, 30mL advancing to 60mL)

Post op day 2-14

vBariatric Stage 2 (full liquids, mostly protein shakes)

Post op day 15-30

vBariatric Stage 3 (pureed, baby food consistency)

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Lifetime Changes

v Low fat, low carbohydrate, HIGH protein dietv60-80 grams of protein per day

v<1000 calories per day

v Be active!v30 minutes per day, 5 days per week

v Daily multivitamin; vit D, B12 & calciumv Social Changesv No carbonated beverages, no strawsv Limit or avoid alcohol, sugary drinksv Stay hydrated (64 ounces of liquids daily)

Bariatric Case Study

v 61 yo female with Lapband placed in 2010

v Struggled to find her green zone and had limit weight lossvOSA, HTN, OA, HLD, hypothyroid, mild

anxietyv Seeking revision to sleeve gastrectomyv Starting weightv256 lbs & BMI 40.09

v After 3 month journey to surgeryv243 lbs & BMI 38.06

Crestor

Mavik

Lodine

Armour

ZoloftXanax prn

HTCZ

CPAP

Post-op follow up

3 monthsv210 lbs

vBMI 32.89

vTrip to the zoo

6 monthsv187 lbs

vBMI 29.2

vNo joint pain & shopping is FUN again

9 months

Armour

ZoloftXanax prn

HTCZ

Take Away Pearls

Medical Weight Management

v Rx therapy indicated vBMI > 30

vBMI > 27 with comorbidity

v Rx MUST be coupled with behavior modification, dietary counseling & increased physical activity

Bariatric Surgery

v Surgery is indicated with:vBMI > 40

vBMI > 35 with comorbidityvHTN, HLD, DM, OSA, OA

v Multi-disciplinary team & ongoing connection with comprehensive program is essential

ICD-10 Obesity Related Codes

E66.01 Morbid (severe) obesity due to excess caloriesE66.09 Other obesity due to excess caloriesE66.1 Drug induced obesityE66.2 Morbid (severe) obesity with alveolar hypoventilationE66.3 OverweightE66.8 Other obesityE66.9 Obesity, unspecifiedAlso include code for BMI (Z68.__)

Other codesZ71.3 Nutritional CounselingE88.81 Metabolic SyndromeR63.2 PolyphagiaR63.5 Abnormal weight gainG47.33 OSA

References

Bays HE, Seger, J, Primack C, Long J, Shah NN, Clark TW, McCarthy W. Obesity Algorithm, presented by the Obesity Medicine Association. 2017-2018. www.obesityalgorithm.org [Accessed 3 May, 2018]

Bloemendaal van L. et al. Effects of glucagon-like peptide 1 on appetite and body weight: focus on the CNS. J Endocrinol 2014;221:T1-T16

Cardiovascular effects of Glucagon-like peptide 1 (GLP-1) receptor agonists - Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/Pleitropic-effects-of-GLP-1-or-GLP-1R-agonists-Adapted-from-references-24_fig2_267740019 [Accessed 5 Aug, 2018]

Golden A. Current pharmacotherapies for obesity: A practical perspective. J Am Assoc Nurse Pract. 2017; 29(S1): S43-S52.

Hess MA, Garvey WT. Assessment and management of patients with obesity

Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: A report of the American College of Cardiology, American Heart Association Task Force on Practice Guidelines, and The Obesity Society. J Am Coll Cardiol. 2014; 63(25 Pt B); 2985-3023.

Pereira, Mark A et al.Fast-food habits, weight gain, and insulin resistance (the CARDIA study): 15-year prospective analysis. The Lancet, 2005; 365: 9453 , 36 – 42.

Reges O, Greenland P, Dicker D, et al. Association of Bariatric Surgery Using Laparoscopic Banding, Roux-en-Y Gastric Bypass, or Laparoscopic Sleeve Gastrectomy vs Usual Care Obesity Management With All-Cause Mortality. JAMA. 2018;319(3):279–290. doi:10.1001/jama.2017.20513

Trust for America's Health and Robert Wood Johnson Foundation. The State of Obesity 2017 [PDF]. Washington, D.C.: 2017

2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults, Volume: 129, Issue: 25_suppl_2, Pages: S102-S138, DOI: (10.1161/01.cir.0000437739.71477.ee)

https://stateofobesity.org/files/stateofobesity2017.pdf

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Resources

www.asmbs.orgwww.obesitymedicine.orgwww.obesityaction.orgwww.obesity.aace.comwww.obesity.org

http://www.asmbs.org/

http://www.obesitymedicine.org/

http://www.obesityaction.org/

http://www.obesity.aace.com/

http://www.obesity.org/

8/13/18 - cdn.ymaws.com

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