Advances in the Understanding &
Treatment of Morbid Obesity
Christopher Still, DO, FACN, FACP
Director, Center for Nutrition & Weight Management
Geisinger Health Care System
2
Who Am I??
É Internist
É Master of Science in Clinical Nutrition
É Residency: Internal Medicine
É Fellowship: Obesity Treatment &
Nutrition Support
É Board certified:
É American Board of Internal Medicine
É American Board of Nutrition
É American College of Nutrition
É National Board of Nutrition Support
3
Why all the Interest in Obesity
Treatment?
Why all the Interest in Obesity
Treatment?
•Discovery of "obesity genes"
•Management: Medical / Surgery
•Epidemic
*
•Discovery of "obesity genes"
•Management: Medical / Surgery
•Epidemic
*
4
More Than One Half of US Adults
Are Overweight or Obese
12.8%
14.1%
14.4%
22.3%
31%
0
10
20
30
40
50
60
70
80
US Population
Age
20+
(%)
1960-1962
NHES
1971-197
NHANES I
1976-1980
NHANES II
1988-1994
NHANES III
2003
NHANES
Overweight or Obese US Adults
BMI 25 -29.9
BMI ≥30
BMI 25 -29.9
BMI ≥30
NHLBI. Obes Res. 1998;6(suppl 2):51S-209S.
Flegal, et al. Int J Obes. 1998;22:39-47.
43.3%
46.1%
46.0%
43.3%
46.1%
46.0%
55.0%
55.0%
63%
63%
39%
73%
2008
5
WEIGHT
WEIGHT
Appetite
• Mood
• Stress
Appetite
• Mood
• Stress
Food
• Availability
• Composition
Food
• Availability
• Composition
Metabolism
• Genetics
• Medications
Metabolism
• Genetics
• Medications
Exercise
• Time
• Compliance
Exercise
• Time
• Compliance
6
Energy Savers
personal computers
tele-commuting
cellular phones
e-mail/Internet
shopping by phone
food delivery services
phone extensions
dishwashers
escalators/elevators
cable movies
drive-thru windows
computer games
intercoms
moving sidewalks
remote controls
garage door openers
8
WEIGHT
WEIGHT
Appetite
• Mood
• Stress
Appetite
• Mood
• Stress
Food
• Availability
• Composition
Food
• Availability
• Composition
Metabolism
• Genetics
• Medications
Metabolism
• Genetics
• Medications
Exercise
• Time
• Compliance
Exercise
• Time
• Compliance
9
Prescription Medications that May
Promote Weight Gain
•Antidiabetics
•Antipsychotics
•Anti depress ants
•Antiepileptics
•Steroids
•Anti histamines
Definition of Obesity
Definition of Obesity
11
Body Mass Index (BMI)
Body Mass Index (BMI)
•Defined as weight (kg)/ height (m)2
•Evaluates weight relative to height
•Replaces the percentage of ideal body
weight
•Correlates highly with body fat and with
morbidity and mortality
•Defined as weight (kg)/ height (m)2
•Evaluates weight relative to height
•Replaces the percentage of ideal body
weight
•Correlates highly with body fat and with
morbidity and mortality
12
13
z
z
z
z
z
z
z
Ñ
Ñ
Ñ
Ñ
Ñ
Ñ
Ñ
2.5
2.5
2.0
2.0
1.5
1.5
1.0
1.0
0
0
20
25
30
35
40
20
25
30
35
40
BMI
BMI
Mortality
Ratio
Mortality
Ratio
1
1
Moderate
Risk
Very
Low Risk
Low Risk
Moderate
Risk
High Risk
Very
High Risk
Men
Men
Women
Women
Ñ
z
Digestive and
pulmonary disease
Cardiovascular and
gallbladder disease
Diabetes mellitus
Obesity and Mortality Risk, 1989
Obesity and Mortality Risk, 1989
1
1
Adapted with permission from Gray DS.
Adapted with permission from Gray DS. MedClin North Am.
MedClin North Am. 1989;73:1 1989;73:1
14
•Abnormal
PFTs
Pulmonary disease
•Obstructive sleep apnea
•Hypoventilation syndrome
Gall bladder disease
•PC OS
Gout
Stroke
•Diabetes
Cardiovascular disease
•Hyperlipidemia
•Hypertension
•Metabolic Syndrome
•Breast, uterus, cervix
Cancer
•Colon
•Prostate
•Steatosis
Liver disease
•NA SH
•Cirrhosis
Phlebitis
Medical Co-Morbidities
Osteoarthritis
PCOS = polycystic ovarian syndrome
NASH = nonalcoholic steatohepatitis
NIH/NHLBI. September 1998; NIH publication no. 984083.
Gynecologic/Urologic abnormalities
•Abnormal
menses
•Infertility
•Stress incontinence
Premature Death
Depression
GERD
So How Do We Treat Obesity?
So How Do We Treat Obesity?
16
Components of an Effective
Obesity Management Program
Wadden TA, Foster GD. Behavioral treatment of obesity. Med Clin North Am. 2000;84:441-461
Stumbo, PH, et. al. Dietary and medical therapy of obesity. SurgClin N Am 85(2005)703-723
Diet
Physical
Activity
Behavior
Modification
Medications
or
Surgery
17
•Standardized meal plans instructed by RDs
-1200 -1500 Kcal, 25% -30% fat
-1500 -1800 Kcal, 25% -30% fat
-ADA (food exchanges) diabetes, PCO, etc.
•Daily food logs ∆journal
•Weekly weigh-in
•"Occurrence" exercise program
•Water
intake
•Behavior modification lessons
•Pharmacotherapy if weight loss plateaus
•Bariatric surgery after comprehensive process
Medical Management
Treatment Plan
18
Diet and Physical Activity
Pavlou KN, et al. Am J Clin Nutr. 1989;49:115-1123
Exercise
Nonexercise
Balanced caloric deficit diet
Protein-sparing modified fast
0-
0-
2-
2-
4-
4-
6-
6-
8-
8-
10-
10-
12-
12-
14-
14-
16-
16-
1 2 3 4 5 6 7 8 9 10 11 12
1 2 3 4 5 6 7 8 9 10 11 12
30
30
Treatment (wk)
Follow-up (mo)
Weight
loss/gain
(kg)
19
Presently Approved
Weight Loss
Medications
20
21
Weight Loss Medications
monitor b/p
GI symptoms
monitor b/p
Concerns
3.6 kg (7.92#)
2.59 kg (5.7#)
4.5 kg (9.9#)
Average Weight
Loss at 1 yr
15-37.5 mg
120 mg TID
10-15 mg
Dosage
induces satiety
blocks fat
absorption
induces satiety
Mechanism of
Action
phentermine
Adipex3
orlistat
Xenical2
sibutramine
Meridia1
Epocrates Rx Online. San Mateo (CA): Epocrates, Inc. 2003-(cited 2006 Jan 23). http://www2.epocrates.com
Zhaoping Li, MD, PhD, et. al. Meta-analysis: Pharmacologic Treatment of Obesity. Ann Intern Med. 2005;142:532-546.
1Knoll Pharmaceutical Company. 2 Roche Group. 3 Phentermine (generic)
Bariatric Surgery
23
Why Consider Surgery ?
•Men with a BMI >40, ages 25-34, have a
12-fold increase in overall mortality
•Plus the morbidity of the obesity related
medical problems
•Decrease in quality of life
•Management of obesity related co-morbities
(DM,OSA, HTN, CHF,DJD)
24
Treatment for Morbid Obesity
•Surgery is only a TOOL
•NOT a cure
25
Indications for Bariatric Surgery
CMS (2006)
-BMI >35 w/co-morbid condition
-Documented ineffective weight loss attempts
- Center of Excellence
-Specific procedures: RNY (open & lap), LAGB®,
BPD, BPD/DS; excludes VBG
-Surgery-for treatment of co-morbidities and
medical complications related to obesity
Decision Memo for Bariatric Surgery for the Treatment of MO (CAG0025OR)
26
Surgical Intervention
Adjustable Gastric Band
(Lap-Band®)
Roux-en-Y Gastric Bypass
27
Multidisciplinary Team Approach
æ Bariatric Surgeons
æ Physician / Bariatrician
æ Case Manager
æ Nurse Specialist / Diabetes Educator
æ Registered Dietitians
æ Exercise Physiologist/ Physical Therapist
æ Behavioral Psychologist
æ Research coordinator and technician
æ Insurance Coordinator
28
Overview of Bariatric Surgery Process
• Stop smoking 60 days prior to surgery
• 10% weight loss from initial presentation
• Read book/complete 10 behavior modification
modules
• Attend 2 educational groups sessions
• Attend 2 patient support groups
• Metabolism / body composition determination
• Psychiatric evaluation
• Medical evaluation
• Surgical evaluation
29
Patient Steps to Bariatric Surgery
• First Month:
- Initial consultation with physician/Fellow or PA-C
- Initial consultation with Registered Dietitian
- Complete WLR, QOL, BDI, & mood survey
questionnaires, obtains disease specific serologies
- Administer physical function testing
- Investigate insurance coverage
30
Patient Steps to Bariatric Surgery
• Second Month:
- Seen by physician, dietitian or mid-level provider.
- Access compliance with prescribed meal plan and
behavior modification
• Third Month:
- Bariatric education class #1 (20-25 patients)
- Obtain required readings and modules
- Seen by physician before or after 1 hr group
- Attend bariatric support group
31
Patient Steps to Bariatric Surgery
• Fourth Month:
- Medical evaluation
- Review 4 stages of post-operative diet by RD
- Metabolism / body composition determination
- Quit smoking (2 months prior to surgery)
- Schedule psychiatric consultation
- Repeat QOL, BDI, Mood survey questionnaires
- Schedule serology's, RUQ U/S, cardiac/sleep evals
- Repeat physical function tests
32
Patient Steps to Bariatric Surgery
• Fifth Month:
- Bariatric Education Class #2 (20-25 patients)
• Lead by Bariatric Surgeon
- Seen by physician before or after group
session
- Attend bariatric surgery support group
33
Patient Steps to Bariatric Surgery
• Sixth Month:
- Access required weight loss (10%)
- Access for smoking cessation
- Access "green" light from RD and Psych.
- Access attendance at support groups (2)
- Obtain Post operative liquid diet
- Obtain referral from PCP to surgeon
• Pre-authorization letter and supporting
materials sent to insurance carrier for
reimbursement approval
34
Patient Steps to Bariatric Surgery
• Seventh Month:
- Consultation with bariatric surgeon
- Obtain surgical Date
• Complete 1 week liquid diet trial
prior to surgery
35
Peri-operative Hospital care
• Followed by bariatric medicine "team" during
hospital stay for medical management
• Follow laparoscopic / open postoperative
protocols during hospital stay
• Discharged home on day 2 or 3 on liquid
diet to follow up with surgeon and bariatric
medicine team in 7 to 10 days.
• Follow-up phone call 3 days post discharge
by bariatric medicine team
36
Post Operative Bariatric Care:
7-10 days Post-op
• Matched appointment with bariatric
surgeon and internist
• Adjust medications
• Access fluid/protein intake, N/V, etc.
• Advance diet on post op day 15.
37
Post Operative Bariatric Care:
1 month Post-op
• Matched appointment with Internist and RD
and surgeon.
• Adjust medications/ begin chewable MVI
• Advance to "stage 3" meal plan at 1 month
post op.
• Administer physical function testing
38
Post Operative Bariatric Care:
2 months Post-op
• Matched appointment with Internist, RD and
surgeon.
• Advance to "stage 4" meal plan
• Begin calcium citrate with vitamin D
• Obtain B12 injection and Q 3 months
• Complete QOL, BDI and mood survey
questionnaires
• Administer physical function testing
• Return appointment Q 3 months x 2 then Q 6
months
39
Post Operative Bariatric Care:
Routine Follow up Visits
• Vitamin B12 injection Q 3 months
• PTH Q 6 to 12 months*
• Physical function testing Q 3 to 6 months
• Complete QOL, BDI, Mood surveys Q 6 M
• Repeat liver biopsy if needed at 1 year
• Repeat metabolism / body comp
determination at 3 to 6 month intervals
• Follow up serology's as indicated
40
Medical Management Post Surgery
•Nausea /vomiting / dehydration
•Medication adjustment
•Nutritional supplements
•Laboratory testing
•Psychological adaptations
•Relapse prevention for a chronic disease
41
Nausea/Vomiting/Dehydration
•Causes of Nausea/Vomiting:
-Dehydration
-Pain medications
-Vitamin supplementation
-Eating too much or too quickly
-Not chewing food adequately
-"small pouch syndrome"
•Patients unable to keep down fluids for a 24 hour
period should be evaluated for possible
obstruction and/or dehydration.
42
Nausea/Vomiting/Dehydration
•Recurrent Nausea:
-Re-hydration and antiemetic medications
•Nausea and Vomiting:
-Thiamin/folate and a multiple vitamin in the IVF
needed to prevent thiamin deficiency and
Wernicke's encephalopathy
43
Diarrhea
•Causes:
-Occult ingestion of sugar in medications/food
-Malabsorption
-New onset (often temporary) lactose intolerance.
- Clostridium difficile colitis
-Dumping syndrome
•Jejunum's response to undigested carbohydrates
•Enteroglucagon and other gut hormones cause an influx of
fluid into the lumen
•Runny nose, excessive salivation, nausea/vomiting,
tachycardia, pre-syncope and diarrhea can occur.
44
"Metabolic" Management
•Antidiabetic Medications
-Insulin requirements fall immediately after surgery
-Oral agents usually held and replaced with SSI
•Antihypertensive Medications
-Usually reduced in dosage or discontinued
-Diuretic held
•Antilipid Agents
-Usually held during the early postoperative period
-Tendency to produce nausea
45
Medication Adjustments
•Essential medications should be administered in
"regular-release" rather than sustained
release/matrix formulations to offset the altered
GI absorption/anatomy after surgery.
•Tolerance can be improved by crushing the
tablets or liquid formulations during the early
postoperative days.
46
Pregnancy after Bariatric surgery
•Not recommended for at least 12 months
•OC not adequate due to altered absorption
•If pregnancy does occur, HIGH RISK OB
and monthly f/u for adequate protein and
nutrient intake
47
Alcohol Intake After Gastric Bypass
•Patients after gastric bypass frequently
comment that they are more sensitive to
the effects of alcohol after surgery.
•Due due reduced body weight for same
number of drinks prior to surgery.
•Patients have higher concentration of
alcohol per kg body weight after surgery.
48
Weight Loss After Gastric Bypass
•First three months: 0.5 lb / day
•Month 3 -6:
3 -5 lb/week
•Nadir:
9 -18 months
Success: 50% of excess body weight or more kept off > 10
years
49
Why Consider Bariatric Surgery ?
•NOT a cosmetic procedure
•Cure or improve obesity related co-
morbidities
50
Effects of Bariatric Surgery on
Diseases of Obesity at Geisinger
Condition
Prevalence
Cured
Improved
HTN
25 -60%
60-66%
90%
Diabetes
25-35%
85-90%
100%
Dyslipidemia 25-40%
70%
95%
51
Effects of Bariatric Surgery on
Diseases of Obesity at Geisinger
Condition
Prevalence
Cured
Improved
Asthma
10-15%
>95%
100%
Heart failure
10%
60% 90%
Sleep apnea
22%
60-80%
100%
Unemployment
62% 35%
52
0.68%
6.17%
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
BARIATRIC*
CONTROLS
MORTALITY
*Includes peri-operative (30-day) mortality of 0.4%
p-value 0.001
Christou (McGill University, Montreal, Canada)
Implication of not managing morbid obesity
89% REDUCTION IN RISK OF DEATH OVER 5 YEARS
Realistic Expectations
Realistic Expectations
54
Mokdad AH, et al.
Mokdad AH, et al.
JAMA.
1999;282:1519-
JAMA.
1999;282:1519-
1522.
1522.
Prevalence of Obesity, 1991
No data
No data
<10% obese
<10% obese
10-15% obese
10-15% obese
>15% obese
>15% obese
55
Mokdad AH, et al. JAMA. 1999;282:1519
Mokdad AH, et al. JAMA. 1999;282:1519
-1522.
-1522.
Prevalence of Obesity, 1998
10-15% obese
10-15% obese
>15% obese
>15% obese
56
Conclusions
•Bariatric surgery is highly effective treatment for morbid
obesity and it's comorbidities and should be offered to
morbidly obese patients who fail conservative management
•Compared to medical management, surgery results in
more profound and long term weight and comorbidity
improvements
•To ensure optimal outcomes surgery needs to be
performed within a multidisciplinary program with
aggressive pre and postoperative management.
•Bariatric surgery is a key part of the spectrum of
treatments for morbid obesity
57
58