pharmacologic treatment considerations for the obese patient shala swarm, fnp-bc cheyenne regional...
TRANSCRIPT
Pharmacologic Treatment Considerations for the
Obese Patient
Shala Swarm, FNP-BCCheyenne Regional Medical Center
Cheyenne Physician’s Group
Weight Loss Center
No Disclosures
Objectives
• Identify three major Health Effects Obesity causes for patients and importance of addressing and treating obesity
• Select at least one treatment option for obesity for patients with major health conditions
Ideal Body and BMI
Ideal Body WeightMetropolitan Life Insurance Table
Method to Calculate
Women = 100 lbs for 5’0” +
5 lbs for each add. inch +/- 10%
Men = 110 lbs for 5’0” +
5 lbs for each add. Inch
+/- 10%
Body Mass IndexHeight to Weight Ratio
Method to Calculate
BMI = Weight (pounds) X 703
Height x Height
(inches)
Ideal Body Weight Charts
HEIGHT SMALL MEDIUM LARGE
(In Shoes)+ FRAME FRAME FRAME
Feet Inches
5 2 128-134 131-141 138-150
5 3 130-136 133-143 140-153
5 4 132-138 135-145 142-156
5 5 134-140 137-148 144-160
5 6 136-142 139-151 146-164
5 7 138-145 142-154 149-168
5 8 140-148 145-157 152-172
5 9 142-151 148-160 155-176
5 10 144-154 151-163 158-180
5 11 146-157 154-166 161-184
6 0 149-160 157-170 164-188
6 1 152-164 160-174 168-192
6 2 155-168 164-178 172-197
6 3 158-172 167-182 176-202
6 4 162-176 171-187 181-207
TABLE 11999 METROPOLITAN HEIGHT AND WEIGHT TABLE
According to Frame, Ages 25-59MEN
Weight in Pounds (In Indoor Clothing)*
HEIGHT SMALL MEDIUM LARGE
(In Shoes)+ FRAME FRAME FRAME
Feet Inches
4 10 102-111 109-121 118-131
4 11 103-113 111-123 120-134
5 0 104-115 113-126 122-137
5 1 106-118 115-129 125-140
5 2 108-121 118-132 128-143
5 3 111-124 121-135 131-147
5 4 114-127 124-138 134-151
5 5 117-130 127-141 137-155
5 6 120-133 130-144 140-159
5 7 123-136 133-147 143-163
5 8 126-139 136-150 146-167
5 9 129-142 139-153 149-170
5 10 132-145 142-156 152-173
5 11 135-148 145-159 155-176
6 0 138-151 148-162 158-179
TABLE 11999 METROPOLITAN HEIGHT AND WEIGHT TABLE
According to Frame, Ages 25-59WOMEN
Weight in Pounds (In Indoor Clothing)*
Indoor clothing weighing 5 pounds for men and 3 pounds for womenShoes with 1-inch heels
Source of basic data Build Study, 1979. Society of Actuaries and Association of Life Insurance Medical Directors of America, 1980.Copyright© 1996, 1999 Metropolitan Life Insurance Company
Courtesy of the Metropolitan Life Insurance Company.
Definitions of Overweight and Obesity
Normal Range – BMI 20-24.9
Overweight – BMI 25-29.9
Obese – BMI 30- 34.9
Severe Obese – BMI 35-39.9
Morbid Obese – BMI 40-49.9
Super Obese – BMI > 50
OBESITY IS A GROWING CONCERN
Obesity Trends* Among U.S. AdultsBMI > 30
Obesity Trends* Among U.S. Adults
Obesity Trends* Among U.S. Adults
Obesity Trends* Among U.S. Adults
Obesity Trends* Among U.S. Adults
Obesity Trends* Among U.S. Adults
StatisticsWorld
•Worldwide obesity has more than doubled since 1980.•In 2008, 1.5 billion adults, 20 and older, were overweight. Of these over 200 million men and nearly 300 million women were obese.•65% of the world's population live in countries where overweight and obesity kills more people than underweight.
Resource: World Health Organizationhttp://www.who.int/mediacentre/factsheets/fs311/en/
US
33.8 %
or one-third
of the
population
Resource: CDChttp://www.cdc.gov/obesity/data/trends.html#National
Wyoming
In 2010 was:
25.1 %
Resource: CDChttp://www.cdc.gov/obesity/data/trends.html#National
Risks of Obesity
Co-Morbid Medical Conditions
• Diabetes• Hypertension• Hyperlipidemia• Cardiac Disease• Sleep Apnea /
Hypoventilation• Liver disease• Cancer risk
• Heartburn• Asthma• Osteoarthritis• Depression• Urinary Incontinence• Menstrual Irregularity• Infertility• Leg Swelling
Complications of morbid obesity are LETHAL
Morbidly obese:
die 10 to 15 years earlier
0
1
2
3
4
20 25 30 35 40
Mort
ality
Rati
o
Body Mass IndexFontaine KR, Redden DT, Wang C, Westfall AO,Allison DB. Years of life lost due to obesity. JAMA. 2003;289:187-193.
What Causes Obesity
Environment ???• Decreased Mobility due
to increased access• Fast Food• Video Games• Sedentary Jobs
Genetics???• Takes many years
to these dramatic
changes
Weight Gain Cycle
Genetic Weight gain Environment
Appetite cravings
reduced energy expenditureMetabolic
Hormonal
Co-morbid disease
Other Causes
Medications:– Anti-psychotics– Anti-depressants– Anti-epileptic's– Steroids– Diabetes meds– Birth Control medications
Other Causes
Health Conditions– Endocrine Disorders– Hormonal Disorders– Sleep Apnea– Diabetes– Orthopedic Injuries
WHAT DO YOU DO WITH THESE PATIENTS?
How do you treat them?
Goals
• Long term vs Short term• Realistic• Small weight reduction can make a big
differenceo A good starting goal is 10% weight losso 10% weight loss can make a big impact on multiple health
conditions
• Prevent more weight gain
Treatment Options
• Screening Tests• Diet• Exercise• Psychological Evaluations• Medications• Surgery
Screening • History• Physical Exam• EKG• Special Measurements and Tests• Labs
CBC CMP Thyroid Panel (TSH, free T3, free T4) Lipid Profile UA Fasting Insulin, 2 hour post-prandial glucose 25 (OH) D levels
Diet
Calorie – a way to measure energy
Calories in = Calories out
1 Calorie = 1 kilocalorie = 1000 calories
Diet
Basal Metabolic rate (BMR)The energy used to sustain life (breathing, cell functions)
+
Thermic effect of food (TEF)Energy used to digest food
+
Activity Thermogenesis (AT)Energy used during exercises
and activities of daily living (NEAT)
Diet
BEE calculation (Harris-Benedict estimation)
BEE Females = 655.1 + (9.563 * Weight) + (1.85 * Height) - (4.676 * Age)
BEE Males = 66.5 + (13.75 * Weight) + (5.003 * Height) - (6.775 * Age)
Diet
Factors that Alter Metabolic Rate• Body Composition (leaner have higher BMR)• Age• Growth• Hormones• Stress• Temperature Changes• Fasting• Dieting• Caffeine, Alcohol, and Smoking
Diet
Increasing Metabolism• Regular Eating Habits• Exercise• Increasing muscle mass
DietFood Label
• RDA vs DV – – DV is a % based on a 2000 calorie diet – RDA is recommended daily allowance (guidelines to promote optimal
health to prevent deficiencies) These are not on the food label.
• Serving Size and amount per container • Calories• Protein• Sugars• Dietary Fiber
Diet• Protein 4 kcal/gm
DRI: 0.8gm/kg of IBW (Increased amounts needed to protect lean body mass in restricted calorie diets)
Growth and repair of body tissues
Sources: meat, fish, legumes, dairy, peanuts
• Carbohydrates 4 kcal/gmDRI: 130 gm/day
Energy Source
Sources: grains, fruits, vegetables
• Fat 9 kcal/gmAcceptable Ranges: 20-35% of daily kcal
Helps with digestion and absorption of fat soluble vitamins
Saturated, Monounsaturated, Polyunsaturated and Essential
• Alcohol 7 kcal/gmNo nutrient value
*DRI – Dietary References Intake
Diet
Keys to Success• Portions• Planning Ahead (meal planning and spacing of meals)• Protein• Conscious Eating• Liquid Calories vs Solid Food• Water Intake
Diets
Types of Diets• VLCD (very low calorie diets – 400-800 cal/day)
• LCD (low calorie diets – 800-1500 cal/day)
• Self Directed (Weight Watchers, Atkins)
DietVLCD• Medically Supervised• The lower the calories, the higher the protein
needed (1.2 g/kg women, 1.5 g/kg men)
• Short term• Vitamin Supplementation• Side Effects: GI, electrolyte, gout, psych, skin, neurological
• Contraindications: many
Diet
LCD• Medically Supervised• More compliance• Weekly Visits• Done by portion control, low-fat, low-carb, or
calorie counting
Diet
Protein and Weight Loss• Changes Body Composition by decreasing
body fat but protects lean tissue mass (protein synthesis in muscles and burning of calories)
• Stabilizes Blood Sugars (insulin levels)• Satiety
Reference: Layman
Diet
Protein Diets – Safety and Monitoring• UA• Vitamins
– Multi-vitamin– Calcium if needed– Vitamin D– Fish Oil
Physical Activity
• Exercise – planned activity• NEAT (non-exercise activity thermogensis)
Daily Activities
Exercise• Aerobic or Cardiovascular
Uses fatty acids for fuel
Cardiovascular fitness
Long bursts of activities
Oxygen dependant (breakdown of ATP)
• Anaerobic or ResistanceIntracellular glycogen as fuel
Improves lean body mass
Oxygen independent (lactic acid build-up)
Reference: Williams Circulation 2007
Exercise
Preventing Injury• Warm up and cool down and stretching
– Always warm up before stretching (optional)– Cool down (below target heart rate level) then stretch
• Body Recovery (resistance needs rest day)• Interval Training (not everyday)• Use guide – ACSM’s Guidelines for
Exercise Testing
Psychological Evaluation
• Eating Disorders• Emotional Eating (depression)• Stress• Eating Patterns• Being Overweight “protecting” patient• Support Systems
Meds, Meds, and more Meds
Medications
• Most are short term use only (but obesity is chronic)
• Safety • Addiction• Cost
**ALL MEDICATIONS NEED TO BE USED WITH BEHAVIORAL MODIFICATIONS OR THEY WILL NOT BE EFFECTIVE**
MedicationsRegulatory Challenges• Efficacy• Safety• Benefit-risk evaluation• History of obesity medications• Perception
MedicationsHistory of Obesity Medications
Drug Year Approved Year Removed
Short Term Use
Desoxyephedrine 1947 ??????
Phenmetrazine 1956 ??????
Phentermine 1959 Still On Market
Diethylpropion 1959 Still On Market
Phendimetrazine 1959 Still On Market
Benzphetamine 1960 Still On Market
Mazindol 1973 ??????
Fenfluramine 1973 1997
Long Term Use
Dexfenfluramine 1996 1997
Sibutramine 1997 2010
Orlistat 1999 Still On Market
http://www.fda.gov/ohrms/dockets/ac/04/briefing/2004-4068B1_05_Approved-Drugs.htm
Medications
• Ephedrine (available as a restricted prescription medication)
• Phentermine (FDA approved 1957)
• Diethylpropion• Phendimetrazine• Benzphetrazine• Xenical• Merida (pulled off market fall 2010)
MedicationsEphedrine
• Dose Range 12.5-75 mg/day• Norepinephrine releaser• Used mainly for hypotension and bronchospasms• Ephedra was herbal form that was banned in 2004• Side Effects: tremors, nervousness, insomnia, increase HR and BP• Cautions/Contraindications: MAOI, breastfeeding, hyperthyroidism,
CAD, HTN, arrhythmias, CV disease, DM, glaucoma, seizures, renal
impairment, prolonged use
MedicationsPhenterminePhentermine HCL (Adipex-P, Fastin)
Phentermine Resin (Ionamin)
• Dose 15-37.5 mg/day• CNS Stimulate• Side Effects: palpitations, tachycardia, HTN, insomnia, dizziness,
euphoria, tremors, HA, pulmonary HTN, valvular heart disease, irritability• Cautions/Contraindications: CV disease, pregnancy and lactation, HTN,
hyperthyroidism, glaucoma, agitation, drug abuse, DM
MedicationsDiethylpropion (Tenuate)
• Dose Range: 25-75 mg/day• Similar to bupropion chemically• Side Effects: tachycardia, HTN, pulmonary HTN, valvular heart disease,
seizures, psychosis, hallucinations, leukopenia, constipation, dry
mouth, N/V, diarrhea, abdominal discomfort, anxiety, dizziness, HA,
insomnia, arrhythmias, palpitations• Caution/Contraindications: pulmonary HTN, HTN, arteriosclerosis,
hyperthyroidism, glaucoma, agitations, drug abuse, valvular hear
disease, heart murmur, CV disease, seizure disorder, psychiatric
disorder
MedicationsPhendimetrazine (Bontril)
• Dose Range: 35-105 mg/day• Mechanism of action unknown, CNS stimulant• Side Effects: tachycardia, HTN, pulmonary HTN, restlessness,
agitation, tremor, flushing, sweating, blurred vision, constipation,
nausea, diarrhea, gastric pain, anxiety, dizziness, HA, insomnia,
palpitations, urinary frequency • Caution/Contraindications: pulmonary HTN, HTN, arteriosclerosis,
hyperthyroidism, glaucoma, agitation, drug abuse, valvular hear
disease, heart murmur, CV disease, DM
MedicationsBenzphetamine (Didrex)
• Dose Range: 25-50 mg/day• Mechanism of action unknown, CNS stimulant• Side Effects: psychosis, tachycardia, HTN, cardiomyopathy, cardiac
ischemia, restlessness, agitation, tremor, flushing, sweating,
constipation, nausea, diarrhea, dizziness, HA, dry mouth, insomnia,
unpleasant taste, palpitations, urinary frequency • Caution/Contraindications: HTN, arteriosclerosis, hyperthyroidism,
glaucoma, agitation, drug abuse, valvular hear disease, heart murmur,
CV disease, DM, arrhythmias
MedicationsXenical (Orlistat, Alli)
• Dose Range: 60-120 mg TID• Mechanism of action: inhibits gastric and pancreatic lipases, reducing
fat absorption• Side Effects: angioedema, fat-soluble vitamin deficiency,
hepatotoxicity; oily spotting flatus with discharge, fecal urgency, fatty
stools, oily evacuation, fecal incontinence, URI, influenza, HA,
abdominal pain, back pain, nausea, menstrual irregularities, UTI,
fatigue, arthritis, rectal pain, dizziness, infectious diarrhea• Caution/Contraindications: malabsorption syndromes, cholestasis,
eating disorders• Kidney and Pancreas problems???
Medications
Off Label Use • Antidepressants• Insulin Sensitizers• Anti-Seizures• Combination Therapy• 5-HTP / Carbidopa
Medications
5-HTP = 5-hydroxytryptophanIncreases the production of serotoninOver the counterWide margin of safety Not been associated risk for serotonin syndrome Does not alter cardiovascular parametersRapidly Metabolized by peripheral decarboxylase
Medications
5-HTP = 5-hydroxytryptophanOther Uses: anxiety, depression, alcohol withdrawal, headaches
Side Effects: anorexia, diarrhea, dizziness, drowsiness, eosinophilia,
flatulence, N/V, somnolence, palpitations, insomnia, hypomania, stomach pain, taste disturbance, weight gain
Avoid Use: eosinophilia syndromes, MAOI use, mitochondrial
encephalomyopathy
Caution in: antidepressant use, down syndrome, GI disorders, platelet
disorders, psychiatric disorder history, PUD, renal disease
Medications
AntidepressantsSSRI (selective serotonin reuptake inhibitors) – Increase 5-HT (serotonin) in
the satiety center and down regulate 5-HT2A auto-receptors which increase 5-HT (serotonin) secretion
– Side Effects: dry mouth, insomnia, nausea, tremor, headache, sweating, decreased libido, Serotonin Syndrome
– Weight Loss Success: Limited results, but may be helpful for emotional eating or night time eating syndrome (sertraline)
Medications
AntidepressantsBupropion (Wellbutrin) – Inhibits neuronal uptake of norepinephrine and dopamine
– Chemically like diethylpropion– Side Effects: dry mouth, headache, agitation, nausea, dizziness, constipation,
tremor, sweating, abnormal dreams, insomnia, tinnitus, diarrhea, abdominal pain, anxiety
– Weight Loss Success: Can decrease appetite and cravings
Medications
Insulin SensitizersMetformin (Glucophage)
• Indicated for Diabetes Type 2• Mechanism of Action: decreases hepatic glucose production and
intestinal glucose absorption; increases insulin sensitivity and
peripheral glucose uptake• Side Effects: nausea, diarrhea, flatulence, anorexia, headache,
metallic taste
Medications
Insulin SensitizersByetta (exenatide)
Victoza (liraglutide)
• Indicated for Diabetes Type 2• Mechanism of Action: activates glucagon-like-peptide-1 (GLP-1)
receptor, increasing insulin secretion, decreasing glucagon secretion,
and delaying gastric emptying (incretin mimetic)• Side Effects: nausea, vomiting, diarrhea, nervousness, dizziness,
headache, dyspepsia, decreased appetite
Liraglutide contraindicated in pancreatitis and thyroid carcinoma
Medications
Anti-Seizure MedicationsTopiramate (Topamax)
• Indicated for Seizures and Migraine headaches• Mechanism of Action: modulated GABA-A receptors, weak caronic
anhydrase inhibitor, exhibits state-dependent bloackade of voltage-
dependant Na and Ca channels• Side Effects: dizziness, parathesias, fatigue, difficulty concentrating,
somnolence, weight loss, nervousness, ataxia, diarrhea, nausea,
nystagmus, tremor, fever, taste changes, taste changes, myopia,
nephrolithiasis• Contraindications: increased intraocular pressure
Medications
Others for thought• Probiotics ???• Antibiotics ???• Vitamin D ???
Medications
Combination Therapy
Obesity is a chronic medical condition and just like any other chronic medical condition multiple medications are usually necessary to proper control of the health condition.
Example: HTN, Diabetes
Medications
Combined Medications
Phentermine + 5-HTP/carbidopa• 5-HTP and carbidopa can counteract side effects of phentermine• Dual action with NE release (phentermine) and increased 5-HT
release • Dual mechanism can increase satiety and decrease food craving
Dosing
Phentermine dosing + compounded 5-HTP / carbidopa
5-HTP = 5-25 mg
carbidopa = always 5 mg
Medications
Combination Medications
Both phentermine and wellbutrin
have norepinephrine effects
and therefore recommended
not to use them together
MedicationsWhat may be to come
• Naltrexone + bupropion (Contrave) – rejected by the FDA in February 2011 (Orexigen)
• Topiramate + phentermine (Qnexa) – (Vivus)
• Zonesamide + bupropion (Empatic) – (Orexigen)
• Pramlintide + metreleptin – Amylin Pharmaceuticals
• Lorcaserin (expected to be named Lorqess) - Arena Pharmaceuticals
• Tesofensine - NeuroSearch
• Liraglutide • Exenatide• GLP-1 + PYY 3-36 – Emisphere Technologies
Medications
Thoughts for Research• Safety• Satiety• Side Effects• Long Term• Cost• Look at gut hormones instead of CNS
Thoughts for the Future
Orexigens• Neuropeptide Y (NPY)• Agouti-related protein (AgRP)• Orexin A and B• Melanin-concentrating hormone (MCH)• Ghrelin (activates NPY and AgRP)
Anorexigens• Brain-derived neurotrophic factor • Alpha-melanocyte stimulating hormone
(alpha-MSH)• Pro-opiomelanocortin (POMC)• Serotonin• Cocaine-amphetamine-regulating transcript
(CART)• Leptin ***• Insulin ***
*** Inhibit NPY and AgRP
Other Thoughts
• Need for a safe anti-obesity medication for long term use as obesity is a chronic condition; Short term control is not useful
• Medications should always be used with diet, exercise and behavioral modification changes
• Should get informed consent
Medications
What not to prescribe – HCG dietASBP Statement on HCG diet:
1. The Simeons method for weight loss is not recommended.
2. The Simeons diet is not recommended.
3. The use of HCG for weight loss is not recommended.
ASBP Position Statement on HCG Diet:
http://www.asbp.org/siterun_data/about_asbp/position_statements/doc5858839311268715587.html
Weight Loss Surgery Options
Weight Loss SurgeryGastric restrictive Malabsorptive
1. JI bypass
2. Bilio Pancreatic Bypass
3. Duodenal Switch
4. Gastric Bypass • Long Limb
1. Vertical Banded
Gastroplasty2. Gastric Bypass
3. Gastric Sleeve
4. Gastric Band
Gastric BypassR o u x – e n - Y
Gastric Sleeve L A P A R O S C O P I C
Gastric Band System
How heavy is the average weight loss surgery patient?
Typical Weight Loss surgery patient
Weight Range (pounds)
Nu
mb
er
In E
ach
Ran
ge
Weight Loss Surgery
Candidates for Surgery• BMI >40• BMI >35 with significant co-morbidities• H&P to assess need for cardiac/pulmonary
clearances• Psychological Evaluation• Dietary Screening
Gastric restrictive Malabsorptive
1. JI bypass
2. Bilio Pancreatic Bypass
3. Duodenal Switch
4. Gastric Bypass • Long Limb
1. Vertical Banded
Gastroplasty2. Gastric Bypass
3. Lap Band
Gastric BypassR o u x – e n - Y
Gastric restrictive Malabsorptive
1. JI bypass
2. Bilio Pancreatic Bypass
3. Duodenal Switch
4. Gastric Bypass • Long Limb
1. Vertical Banded
Gastroplasty2. Gastric Bypass
3. Lap Band
Gastric BypassR o u x – e n - Y
Weight Loss SurgeryMal-absorptive Procedures
JI Bypass • Performed from 1950s-1970s• Problems / Complications:
mineral and electrolyte imbalances, protein malnutrition, abdominal discomfort including flatus and diarrhea, liver disease, renal disease, peripheral neuropathy, pericarditis, and more.
BPD / DS• More demanding operation than
the RYGB• Problems / Complications:
diarrhea, foul smelling flatulence, mal-absorption of fat soluble vitamins, protein malnutrition, ulcers, and dumping syndrome.
Gastric Restrictive Procedures
Gastric Restrictive Procedures
B12iron
Ca++
Protein calorie malnutrition
Dehydration
Gastric Restrictive Procedures
Ghrelin receptors
Gastric Sleeve L A P A R O S C O P I C
Gastric BypassR o u x – e n - Y
2nd stage
Gastric Restrictive Procedure
http://asmbs.org/benefits-of-bariatric-surgery/
Weight Loss SurgeryRisks of Surgery
• Complications may include– Mortality (0.24%)– Staple line leaks (RYGB) (0.73%)– PE (0.25%)– DVT (0.17%)– Wound infections (1.8%)– Marginal ulcers– Malnutrition– GI Bleed (0.44%)– Small Bowel Obstruction (0.40%)
Weight Loss SurgerySafety and Monitoring
Routine lifetime follow up• Lap Band: monthly for 6 months and fills
based on symptoms but routine visits for life
• RYGB and Sleeve: 1 week, 1 month, 3 month, 6 months, 9 months, 1 year, 18 months, and annually
• Regular follow up visits help with compliance and better weight loss
Weight Loss Surgery
Safety and Monitoring
Vitamin Supplementation• Bands – multi-vitamin, calcium, fish oil• RYGB / Sleeve – multi-vitamin (bariatric),
calcium, B12, iron, fish oil
Weight Loss Surgery
Routine Labs• Bands – general health screening
(annually)• RYGB / Sleeves – CBC, CMP, folate,
thiamine, B12, total iron, TIBC, ferritin, A1C, lipids, vitamin D, TSH– Annual bone density
Weight Loss Surgery
Diet• Slow diet progression• Food Intolerances• No No Foods• Eating Behaviors that need changed
Weight Loss Surgery
DO NOT
• Prescribe NSAIDS after RYGB• Prescribe steroids after RYGB• Prescribe extended release medications
after RYGB• SMOKE
NIH Consensus
Severe obesity is a
Chronic, intractable, and progressive disorder;
any therapeutic program must, therefore, be
lifelong.
References1. National Institutes of Health (NIH) National Heart, Lung and Blood Institute (NHLBI) North American Association for the Study of Obesity. The
practical guide: identification, evaluation, and treatment of overweight and obesity in adults. NIH; 2000; NIH Publication No. 00-4084.
2. National Institutes of Health (NIH) National Heart, Lung and Blood Institute (NHLBI). Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. NIH; 1998; NIH Publication No. 98-4083.
3. Center for Disease Control. Overweight and Obesity. http://www.cdc.gov/obesity/data/trends.html
4. Center for Disease Control. Overweight and Obesity. http://www.cdc.gov/obesity/data/trends.html#National
5. World Health Organization. Overweight and Obesity. http://www.who.int/mediacentre/factsheets/fs311/en/
6. Build Study, 1979. Society of Actuaries and Association of Life Insurance Medical Directors of America, 1980.
7. Fontaine KR, Redden DT, Wang C, Westfall AO, Allison DB. Years of life lost due to obesity. JAMA. 2003 Jan 8;289(2):187-93.
8. Knight JA. Diseases and disorders associated with excess body weight. Ann Clin Lab Sci. 2011 Spring;41(2):107-21.
9. American Society of Bariatric Physicians (ASBP). Bariatric Practice Guidelines. 2004.
10. American Society of Bariatric Physicians (ASBP). Position statement on HCG diet. http://www.asbp.org/siterun_data/about_asbp/position_statements/doc5858839311268715587.html
11. Millward D, Layman D, et. al. Protein quality assessment: impact of expanding understanding of protein and amino acid needs for optimal health. AJCN 2008 May; 87, (5), 1576S-1581S.
12. Gardner CD, Kiazand A, Alhassan S, Kim S, Stafford RS, Balise RR, Kraemer HC, King AC. Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among overweight premenopausal women: the A TO Z Weight Loss Study: a randomized trial. JAMA. 2007 Mar 7;297(9):969-77.
13. Shai I, et. al, Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet. N Engl J Med. 2008 Jul 17;359(3):229-41.
14. Sacks FM, et. al, Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates. N Engl J Med. 2009 Feb 26;360(9):859-73
15. Mahan L.K, and Escott-Stump, 2000. S. Krause’s Food, Nutrition, & Diet Therapy. 11th ed. Philadelphia, Pennsylvania. Elsevier
16. Epocrates Rx Version 1.371.0. San Mateo (CA): Epocrates, Inc.
17. Food and Drug Administration. FDA Approved obesity drugs. http://www.fda.gov/ohrms/dockets/ac/04/briefing/2004-4068B1_05_Approved-Drugs.htm
18. Heal, D. Gosden, J. and Smith S. 2009. Regulatory challenges for new drugs to treat obesity and comorbid metabolic disorders. BJCP 68:6: 861-874.
19. Hussain, SS and Bloom SR. The pharmacological treatment and management of obesity. Postgrad Med. 2011 Jan: 123 (1): 34-44.
20. Cooke, D and Bloom S. The obesity pipeline: current strategies in the development of anti-obesity drugs. Nat. Rev Drug Discov. 2006 Nov: 5(11): 919-31.
21. Kaplan LM. Pharmacologic therapies for obesity. Gastroenterol Clin North Am. 2010 Mar: 39 (1): 69-79.
References Cont.1. Kootte RS, et. al; The therapeutic potential of manipulating gut microbiota in obesity and type 2 diabetes mellitus. Diabetes Obes Metab. 2011
Aug.2. Ly, NP et. al.; Gut microbiota, probiotics, and vitamin D: interrelated exposures influencing allergy, asthma, and obesity? J Allergy Clin Immunol.
2011. May; 127 (5): 1087-94.3. Weir Ma, Beyea MM, Gomes T., et. al. Orlistat and acute kidney injury: an analysis of 953 patients. Arch Intern Med. 2011 Apr 11;171(7):703-4.4. Brethauer SA, Chand B, Schauer PR. Risks and benefits of bariatric surgery: current evidence. Cleveland Clinic Journal of Medicine (2006)
75(11); 993-1007.5. Anonymous. Perioperative safety in the longitudinal assessment of bariatric surgery. NEJM. 2009 Jul; 361(5) 445.6. Goutham RAO. Office-based strategies for the management of obesity. Am Fam Physician. 2010 Jun 15; 81(12): 1449-1455.7. American Society of Bariatric Surgery (ASMBS). Rational for surgical treatment. http://asmbs.org/rationale-for-surgical-treatment/8. Gastrointestinal Surgery for Severe Obesity. NIH Consensus Statement 1991 Mar 25-27;9(1):1-20. 9. Goldstein DJ, Rampey AH Jr, Roback PJ, Wilson MG, Hamilton SH, Sayler ME, Tollefson GD. Efficacy and safety of long-
term fluoxetine treatment of obesity--maximizing success. Obes Res. 1995 Nov;3 Suppl 4:481S-490S.10. Stunkard AJ, Allison KC, Lundgren JD, Martino NS, Heo M, Etemad B, O'Reardon JP. A paradigm for facilitating pharmacotherapy at a distance:
sertraline treatment of the night eating syndrome. J Clin Psychiatry. 2006 Oct;67(10):1568-72.11. Fontaine KR, Redden DT, Wang C, Westfall AO, Allison DB. Years of life lost due to obesity. JAMA. 2003; 289:187-193.12. AACE/TOS/ASMBS Bariatric Surgery Guidelines, Endocr Pract. 2008;14 (Supp 1)