Transcript Wharton Medical Clinic

Role of Private Bariatric Medical
Centres
ARE WE READY?
Dr. Sean Wharton, MD, FRCPC
Internal Medicine
Wharton Medical Clinic
Adjunct Professor – York University
Lead Author – Obesity Section - CDA Guidelines
CABPS, June 2012
Disclosures
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Grants/support
CIHR
Heart and Stroke Foundation
MITACS – Research
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Honoraria/Advisory Board
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Novo-Nordisk
Merck
Bristol Myers Squibb
Abbott Pharmaceuticals
Eli-Lilly
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AstraZeneca
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Objectives
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Discuss the current environment of community
based bariatric medicine
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Example of a publically funded community
based weight management clinic.
Current Environment
of Medical Bariatric Centres
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Tertiary
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HGH
Ottawa Civic
Edmonton Capital Region – Weight Wise
Community Practices
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Commercial
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Weight Watchers
Bernstein’s
Herbal Magic
Evidence Based Practices
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BMI (Bariatric Medical Institute)
Wharton Medical Clinic
Family Medicine Practices
Yoni Freedhoff, MD
Questions?
Community Based Bariatric Programs
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Standardization
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Funding
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Meal Replacements
 Programs, Partial
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Family Doctors or Specialists
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Team
 Dietitians, nutritionists (bariatric educators), exercise
specialists, behavioural therapist, pharmacist, social work etc.
Answers
Community Bariatric Medicine
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Efficient System – demand is great
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Multi-disciplinary
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Cost-effective
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Family/childhood obesity a priority
115 Programs
Analyzed
31 Surgical Programs
2 Surgical Assessment Centres
82 Non-surgical Programs
32 Community-based (group
session, gym)
41 Primary Health Care (MD,
nurse, dietitian)
7 Hospital-based
115 Programs
ASPQ Criteria for Bariatric Programs
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Rate of weight loss
Multi-disciplinary
Dietary intervention (without long term use of
VLCD)
Physical activity
Effectiveness
Safety
Approach to advertising
Cost Effectiveness
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Pharmacotherapy
3/31 – surgical programs
 12/82 – non-surgical program (11 PC, 1 hosp)
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BMI Criteria
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32/82 nonsurgical programs did not use BMI as
entry criteria
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Primary care based programs show the greatest
compliance. Encouraging – most accessible
Access to hospital-based non-surgical programs
is extremely limited.
Bariatric surgery facilites are lacking in
psychological supports, and physical activity
compared to non-surgical programs.
Long-term weight-loss maintenance: a metaanalysis of US studies
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13 Studies (VLCD and HBD)
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1081 pts - F/U – 4.5 years
Initial weight loss 30.8 lbs (14%)
Weight-loss maintenance 6.6 lbs (3%)
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40.2% of patients maintained - 5% loss at 5 years
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NNT of 2.5
25% of patients maintained - 10% loss at 5 years
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NNT of 5
Anderson et al. Am J Clin Nutr, 2001
Wadden et al. NEJM; Nov 14, 2011
Important aspects of a weight
management clinic
Cost
 medical supervision
 frequent visits
 no pressure/non judgmental
 emotional support
 nutritional support
 convenient location with parking
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How frequently would you like
to come to a professional centre
for a weigh in?
2%
4%
every week
8%
every 2 weeks
34%
2%
every 3 weeks
1/month
Whenever I want
50%
no answer
Wharton Medical Clinic
Weight Management Centre
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Launch – May 2008
A large community based bariatric clinic –
government funded – no charge to patients
9 Internists – 3 Nephrologist, 1 cardiologist, 2 ICU,
1 rheumatologist, 1 haematologist, 1 GIM
 1 Dietitian/15 Nutritionist (Bariatric Educators)
 Behavioural Therapy Team/Physiotherapy Team
 Research Staff
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Bariatric Educators
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Education/Qualifications
BSc Nutrition (Guelph, UWO, Ryerson)
 Post WMC - 2 MDs, 2 Masters, 4 dietitian internship
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Supervision/Quality Control
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Dietitian/MDs
1/2 – 1/3 - salary of a dietitian
Significant dietary concerns – referred to the
dietitian
WMC Clinic
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Adults
BMI 27-30 with 1 comorbidity, or BMI>30
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? Change this to BMI 27 – 40 with 1 comorbidity,
BMI > 40 (no comorbidities needed)
Treatment of cardio-metabolic conditions
Pharmacotherapy
Surgical Referral/Medical and Psychological
Support/Pre and Post Op Management
Wharton Medical Clinic
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May 2012
19,069 pts (76% women)
 3,734 pts current
75 - 100 new pts/week
No waiting list
15-20 min GROUP education session at every visit
MD sees patient at every visit
Visits q 1 – 3 weeks
Metabolic and CV Risk assessment
Evening Educational Classes
Aggressive Diabetes Management
WMC Program Flowsheet
1. FD - ASK
2. ASSESS
3. AGREE
4. ADVISE
Visit #2
BE/MD Visit
Initiate Meal Plan
Visit #1
BE/MD Visit
PMHX/Meds/Exam/
Weight Hx/Consent to
research and Goals
Baseline ECG
Bloodwork
RMR
GXT
Wt, Ht, BMR, WC/HC
Blood pressure
500 calorie/day deficit
Pedometer – walking
Resistance bands/Aqua
Organized eating
Visit q 3- 4 weeks
BE/MD Visit
SUPPORT GROUPS
5. ASSIST
WEEKLY WEIGH-INS ENCOURAGED – not billed to OHIP
Manage medically
Diabetic management
CV management
Referrals
BE #1
Notes
BE #1
Notes
BE #1
Notes
Weight, Ht, BP, WC/HC
BE #1
Notes
BE #2
Presentations
BE #1
Notes
BE #2
Presentations
BE #5
BE #4
BE #3
Individual visit
Individual visit
Individual visit
BE #1
Notes
BE #2
Presentations
BE #5
BE #4
BE #3
Individual visit
Individual visit
Individual visit
BE #1
Notes
BE #2
Presentations
BE #5
BE #4
Individual visit Individual visit
BE #3
Individual visit
WMC - Lectures
Educational Seminars
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Topics
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How to complete a food journal
Macro and micronutrients/label reading
meal plans/eating out
diabetic meal planning
Emotional eating
stress and weight, body image, support group
Activity – pedometers, resistance bands
RMR Machine
Comparison of Group vs. Individual
Treatment for Weight Loss: 6 months
0
Group Treatment
Individual Treatment
Preferred Non-Preferred
Preferred Non-Preferred
Weight Loss (in kg)
2
4
6
8
10
12
14
p < .02
16
Renjilian, Perri et al. J Consult Clin Psychol 2001; 69:717-721.
Barry at 404 lbs, BMI 60
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Past Medical History
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Diabetes Type 2
OSA – CPAP
Hypertension
High Cholesterol
Urinary incontinence
Hernia - ventral
Obesity Class III
Developmental Delay
Intertrigo
Medications
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Metformin, Glyburide
Ramipril, Lipitor
Barry’s Weight Loss Graph
Barry at 231lbs, BMI 33
176lbs lost, 43% WL
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Current Medical Hx
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OSA
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Diabetes type 2
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CPAP turned down
Diet controlled
Obesity Class I
Current Medications
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No medications
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Off – metformin, ramipril,
glyburide. Lipitor
Feasibility of a interdisciplinary
program for weight
management in Canada
Sean Wharton MD; Sarah VanderLelie B.A.Sc;
Saaqshi Sharma M.Sc; Arya Sharma MD;
Jennifer L. Kuk PhD
Canadian Family Physician, Feb 2012;852:32-8
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Descriptive sample
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1085 pts (3 months), 289 pts (6 months)
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77% female
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Age – 49.3 + 12.5 years
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BMI – 40.5 + 8.1 kg/m2
Disease
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Number of
Patients
2500
1500
1000
84%
2000
69%
27%
Canadian Family Physician, Feb 2012;852:32-8
33%
21%
45%
27%
500
0
20%
50
47
Prevalence (%)
43
38
40
28
30
20
10
32
21
6
8
9
1
2
3
13
15
4
5
17
0
Treatment Time (months)
Wharton et al. Can FamPhys, 2012;852:32-8
6
5%
10%
Prevalence of WMC Patients attaining
5% and 10% Weight Loss (18 months)
1,562 patients
Discontinuation
(no visit in 3 months)
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28.9% (N=452)
lost 4.3 kg ± 6.1
 3.7 % ± 5.0 of BW
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31% - 5% weight loss
11% - 10% weight loss
8.4 ± 3.0 visits over 7.5 ± 1.4 months
Results- Prevalence of MNOB and MAOB
Clinical cutoffs
Sub-clinical cutoffs
70%
Prevalence (%)
60%
50%
40%
30%
20%
10%
0%
0
1
2
3
Baseline
4
5
0
1
2
3
Follow-up
Number of metabolic risk factors
4
5
Sex
Female
Male
Percent Weight Loss (%)
0
-1
-2
-3
-4
-5
Ref
-6
Unadjusted data
-7
Data adjusted for independent variables: sex, age group, BMI
class, education, ethnicity and smoking status and treatment
duration)
Age Group
Percent Weight Loss (%)
0
18-49
49-64
>64
-1
-2
-3
-4
-5
*
Ref
*
**
-6
-7
Unadjusted Ptrend = 0.004
Adjusted Ptrend = 0.007
BMI Category
0
OW
OBCI
OBCII
OBCIII
Weight Lost (kg)
-1
-2
-3
-4
-5
-6
-7
Ref
*
Unadjusted Ptrend <0.0001
Adjusted Ptrend <0.0001
BMI Category
OW
OBCI
Percent Weight Loss (%)
0
OBCII
OBCIII
-1
-2
-3
-4
-5
-6
-7
Ref
Unadjusted Ptrend = 0.60
Adjusted Ptrend = 0.84
Education
Less than HS
HS or GED
College
University
Percent Weight Loss (%)
0
-1
-2
-3
-4
-5
-6
Ref
Unadjusted Ptrend = 0.46
-7
Adjusted Ptrend = 0.33
Ethnicity
White
Asian
AFHeritage
Other
0
Weight Lost (kg)
-1
-2
-3
* *
-4
-5
*
-6
-7
Ref
Next steps for
Wharton Medical Clinic Research
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Current Studies
Comparison metabolically normal obese vs
metabolically abnormal obese (submitted)
 Economic analysis of effectiveness data
 Analysis of attrition rates
 OSA in patients unwilling to use CPAP randomized to GLP1 analogue vs placebo
 PGX fibre in diabetics (placebo controlled)
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Application of model to family medicine clinics
Recent publication for the
Wharton Medical Clinic
Research in non-surgical bariatric
medicine
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We are obligated to complete research in this
area – we are still in our infancy.
Conclusion and Questions
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Statement: Community based bariatric medicine
is necessary
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Statement: Results from WMC are promising
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Question: How are we going to pay for it?
Question: How can it get better, more efficient and
even more cost effective
Are we Ready for community based practice?
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Do we have a choice?
Thank You!
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Sarah Vanderlelie, BSc
Jennifer Kuk, PhD
Arya Sharma, MD
Saaqshi Sharma, MSc
Rebecca Liu, MSc
Marcia Villafranca
Blair Leonard, MD
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WMC Team