weight loss surgery seminar a comprehensive overview · gastric bypass, gastric sleeve, duodenal...

Wellness is a Journey, not a destination.

Obesity Treatment

A Brief Overview

Presented by:

Lana G. Nelson, DO, FACOS Medical Director of Metabolic and Bariatric Surgery

Norman Regional Health System


Problem of obesity

Causes of obesity

Treatment options

Clinicians’ role in addressing

obesity

Obesity Treatment Objectives


The Problem

More than 30% of adults are overweight and another

30% are obese

Obesity continues to rise- 50% obesity rate by 2030?

Epidemic rates

Not always recognized or acknowledged

Projected that the generation being raised today may

have a shorter lifespan than we do


Defining Obesity:The Body Mass Index


Obesity Prevalence 2014


Medical Impacts of Obesity

Depression

Anxiety

CVA

Intertrigo

Panniculitis

Sleep apnea

Asthma

Dyspnea

Cholelithiasis

GERD/Reflux

NASH

Cirrhosis Infertility

Menstral irregularities

Polycystic ovaries

Incontinence

Impotence Diabetes

Metabolic Syndrome

Cephalgia

HTN

LEE

Heart disease

Dyslipidemia

Venous ulcers

DVT/PE

Osteoarthritis

Joint pain

DDD

Gout

Cancer:

Prostate

Breast

Uterine

Cervical

Colon


Causes of Obesity-Behavioral

Lack of willpower

Excess eating

Poor food choices

Liquid calories

Lack of exercise/physical activity


Causes of Obesity-Genetic

Rare causes

Common forms

More than 30 genes identified

Multiple variants

Impacts co-morbidities

Predisposition, not destiny


Causes of Obesity-Enviromental

Food availability

Food deserts

Processed foods

High calorie food and drinks

Physical activity

Sedentary jobs

Eating schedules

Sleep health

Local stressors

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwigiOG14ZPKAhXDeSYKHUlRDnAQjRwIBw&url=https://www.mainstreet.com/slideshow/fast-food-desserts-most-calories&psig=AFQjCNH2HAY-YTmtxkRKojywnFDGor3dew&ust=1452120732572142

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiLm8mN4pPKAhUS82MKHbBNCtQQjRwIBw&url=http://www.emilybinder.com/page/2/&psig=AFQjCNGEloR59UWWkE7P5Diwnyyjf3jPmg&ust=1452120884047156

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiplIj845PKAhUBwWMKHc6PCc0QjRwIBw&url=http://arh346.blogspot.com/2014_04_01_archive.html&bvm=bv.110151844,d.cGc&psig=AFQjCNGnju7YDdKja49XPrMg7_L8czaSrQ&ust=1452121408551335


Obesity and Ethnicity

Obesity rates high in

blacks (50% higher)

Hispanics (21% higher)

Mexican Americans

Lower physical activity

Difference in cultural norms

Limited access to healthy foods

Asians experience metabolic derangements at lower

BMI


Oklahoma State Meal

Fried okra, squash, cornbread, barbecue pork, biscuits, sausage

and gravy, grits, corn, strawberries, chicken fried steak, pecan

pie, and black-eyed peas.


Causes of Obesity-Medications

Diabetes meds

Psych agents

Antipsychotics

Anti-seizure meds

Steroids

Hormones

Antihistamines

Beta blockers


We need a new approach…

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Treatment considerations

BMI and

treatment

25-

26.9

27-29.9 30-34.9 35-39.9 ≥40

Diet, behavior,

physical

activity

+ + + + +

Medications - With

comorbidities + + +

Surgery - - Intragastric

balloon or

LAGB with

comorbidities

Intragastric

balloon or

others with

comorbidities

LAGB, RNY,

LSG,

BPDDS


Dietary Options: Induction and

Maintenance VLCD/LCD

Low fat

Calorie restriction

Flexitarian/Vegetarian/Plant-based

Mediterranean


Short-term medications

FDA-Approved Drug Mechanism of Action Comments

Phentermine

(Adipex, Suprenza) Noradrenaline/dopamine

releasing stimulator Schedule IV drug

Phendimetrazine

(Bontril) Noradrenaline/dopamine

releasing stimulator Schedule IV drug

Diethylproprion

(Tenuate)

Noradrenaline/dopamine

releasing stimulator

Schedule III drug

Benzphetamine

(Didrex)

Noradrenaline/dopamine

releasing stimulator

Schedule III drug


Long term medications

FDA-Approved Drug Mechanism of Action Comments

Orlistat

(Xenical) (Alli –OTC) Pancreatic lipase inhibitor

Approved for long-term use in 1999,

blocks fat absoprtion

Phentermine/Topiramate

(Qysmia)

Noradrenaline releasing +

modulator of ɣ

aminobutyric

acid (GABA)/ carbonic

anhydrase inhibition

Approved July 2012

Q and Me Patient support

Lorcaserin

(Belviq) Selective 5-HT2Creceptor

agonist

Approved June 2012

Believe Support

Bupropion/Naltrexone

(Contrave)

Inhibitor of dopamine and

noradrenaline reuptake +

µ opiate antagonist

Approved Sept 2014

Scale Down Program

Liraglutide (Saxenda) GLP-1 agonist Approved December 2014

SaxendaCare


Weight loss from other meds

Medication Indicated Uses Comments

Metformin Type 2 diabetes

PCOS Rare liver toxicity

Sitagliptin (Januvia) Type 2 diabetes Decreases appetite

Exenatide (Byetta) Type 2 diabetes Injectable

Pramlintide (Symlin) Type 2 diabetes Injectable


Weight loss from other meds

Medication Indicated Uses Comments

Lisdexafetamine

(Vyvanse) ADHD, BED

Metreleptin

(Myalept) Leptin disorder Injectable

Bupropion Depression Avoid in bipolar disease

Topiramate Seizures, Migraines

Mood disorders

May produce neurological side

effects

Zonisamide (Zonergan) Seizures

Mood disorders Few studies

Bupropion Depression Avoid in bipolar disease


Exercise Counseling

Chronic exercise alters habits toward healthy food-

decreases appetite and calorie consumption

Increases brown fat

Enhances resting energy expenditure

Lowers energy storage set point

Decreases cardiovascular disease

Increases insulin sensitivity

Improves mood and energy

Aerobic Exercise Alone Results in

Weight Loss: Midwest Exercise Trial 2

-7

-6

-5

-4

-3

-2

-1

0

1

2

3

TotalWeight

Fat Mass

Fat-FreeMass

-7

-6

-5

-4

-3

-2

-1

0

1

2

3

TotalWeight

Fat Mass

Fat-FreeMass

% C

ha

ng

e

% C

ha

ng

e

Females Males

Donnelly et al. Obesity (2013), E219-228

+0.5 vs. -3.9 vs -5.2 kg

Supervised 5 days a week/10 months


Surgical Treatment of Obesity

NIH guidelines

FDA guidelines

Insurance guidelines

Endoscopic and laparoscopic therapies

Multiple mechanisms of action


Contraindications to bariatric

surgery High operative risk

Active substance abuse

Active nicotine abuse

Untreated or uncontrolled psychiatric disease

Inability to understand or comply with expected

changes


Endoscopic Surgery

Endoscopic “sleeve”

Intragastric balloon

Short term device

Short term results

Long term impact unknown

Orbera and ReShape

8-10% of body weight loss

$7000+

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Laparoscopic Bariatric Surgery

Gastric bypass, gastric sleeve, duodenal switch and

Lap-band

Indicated for BMI over 35 with co-morbidities, or over

40

Significant weight loss and reduction in cardiovascular

risk factors

Metabolic side effects

Frequently covered by insurance, including Medicare

Early intervention is best

Investigational in BMI 30-35 with diabetes


US Bariatric surgery trends

2012 2013 2014 2015

Total 173,000 179,000 193,000 196,000

RNY 37.5% 34.2% 26.8% 23.1%

Band 20.2% 14% 9.5% 5.7%

Sleeve 33% 42.1% 51.7% 53.8%

BPD DS 1% 1% 0.4% 0.6%

Revision 6% 6% 11.5% 13.6%

Other 2.3% 2.7% 0.1% 3.2%


Roux-en-Y Gastric Bypass


Roux-en-Y Gastric Bypass

Advantages:

Rapid, consistent weight loss

Sustained weight loss

Immediate impact on diabetes

High improvement in obesity related

health problems

Long term data available

Curbs hunger

Disadvantages:

Invasive

Dumping syndrome

Nutrition deficiencies

Marginal ulcer

No NSAID's


Gastric Sleeve


Gastric Sleeve

Advantages:

No re-rerouting

No dumping syndrome

Able to take NSAIDS

No foreign material

Curbs hunger

May proceed to gastric bypass

or DS if weight loss is

inadequate

Disadvantages:

Not reversible

May worsen reflux

Medium term data


Adjustable Gastric Band


Adjustable Gastric Band

Advantages:

Reversible

No Malabsorption

“Least invasive”

Outpatient procedure

quicker return to work

Plication improves wt loss

Disadvantages:

Higher maintenance

Possible higher cost

May worsen reflux or dilate esophagus

Possibility of re-operation:

slip, erosion, leak, flipped port

Weight loss variable

More effective for lower BMI


Duodenal Switch/SIPS


Duodenal Switch/SIPS

Advantages:

Best weight loss

Best comorbidity resolution

No marginal ulcers

Able to continue NSAIDS

No dumping

Disadvantages:

Higher malabsorption- esp fat soluble

More BMs and Flatus

Technically more difficult

Higher initial morbidity/mortality

Higher BMI pts/severe DM

Follow up most important- need reliable pt


Risk of Weight Loss Surgery

Early:

Death

DVT/PE

Bleeding/transfusion

Injury to adjacent organs

Pneumonia

Atalectasis

Infection

Leakage/perforation

Obstruction/blockage

Late:

Hypoglycemia

Nutritional deficiencies

Osteopenia/porosis

Transfer addiction

Suicide

Hernia formation

Need for additional surgery

Marginal Ulcer formation

Stricture


Procedure Comparison

SIPS Bypass Sleeve Adjustable

Band

Consistent weight

loss

Yes Yes Yes Variable

NSAID Yes No Yes Yes

Controls hunger Yes Yes Yes Variable

Reversible No Yes No Yes

Diabetes

improvement

Yes Yes Yes Variable

Improves reflux Variable Yes Variable Variable


Early Post-operative Medications

• Crushable, liquid, and non ER/SR

• Rapid adjustment of DM meds- use metformin,

insulin, and ultimately incretins

• Avoid sulfonyureas and meglitinides

• Continue B blockers, reduced dose and IR

• Continue statins


Long term monitoring

• Monitor labs annually for mal-absorptive (CBC,

CMP, Prealbumin, Iron/Ferritin, B12/Folate, Vit

D/iPTH, selectively A1C, zinc, copper, lipids,

thiamine, Vit A

• Bone density scan 2 years post op for mal-

absorptive

• Check with bariatric surgeon before stopping

supplements

• Be suspicious of abominal complaints

• Address weight gain quickly and agressively


Routine vitamins

SIPS Bypass Sleeve Adjustable

Band

MVI x2 x2 x2 x1

B Complex Yes Yes Yes No

Calcium Citrate Yes Yes Yes Variable

B12 Yes Yes Yes No

Vitamin D ADEK PRN PRN PRN

Iron Yes Yes No No


Pregnancy after

Weight Loss Surgery

Safer when mom is

metabolically healthier

Weight loss and nutritional

intake have stabilized

Consider nutrition labs prior

to conception

Nutrition counseling

At least 18 months after

surgery


Clinicians’ Role

Recognize the problem

Avoid discrimination

Reinforce need for change

Enable patients who want to change

Monitor progress

Keep patients accountable

Provide positive reinforcement

Be an example


Obesity is a complex disease

Multiple contributors to obesity: physiological,

environmental, genetic, behavioral, psychological,

medications

Multi-modal treatment options: diet therapy, medication,

behavior modification, lifestyle intervention, exercise

counseling, surgery

Requires multidisciplinary evaluation and treatment

No one therapy is effective for all, and many may require

combination therapy


Questions?

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