Transcript obesity - Texas Tech University Health Sciences Center

Pharmacologic and Surgical Management
of OBESITY in Primary Care
Rey Vivo, MD
Assistant Professor of Medicine
Texas Tech University Health Sciences Center
What is the best answer?
• Which of the following is/are true regarding obesity?
• A. Obesity is generally defined as BMI > 30
• B. Last year, only 4 states remain to have obesity
prevalence < 20%
• C. All obese patients, without exception, need
counseling for TLC
• D. Pharmacologic treatment lack long-term safety data
• E. Bariatric surgery, while effective, may have multiple
GI, nutritional and metabolic complications
Objectives
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•
•
•
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Define overweight and obesity
Epidemiology trends
Contributing factors
Health consequences
ACP Management Guidelines
– Pharmacologic
– Surgical
Definitions
• Body Mass Index (BMI)
BMI
– Formula: weight (kg) /
[height (m)]2
– Formula: weight (lb) /
[height (in)]2 x 703
Weight
status
< 18.5
Underweight
18.5 - 24.9
Normal
25 – 29.9
Overweight
30 – 39.9
Obese
> 40
Extremely
obese
• Caveats:
–
–
–
–
Women
Elderly
Highly-trained athletes
Abdominal fat
What is the best answer?
• In 2006, the following states had the lowest
prevalence of obesity (< 20%) except:
•
•
•
•
•
A.
B.
C.
D.
E.
Connecticut
Massachusetts
West Virginia
Hawaii
Colorado
Epidemiology:
Obesity Trend 1990
No Data
<10%
10%–14%
15%–19%
Source: Centers for Disease Control and Prevention
20%–24%
25%–29%
≥30%
Epidemiology:
Obesity Trend 1998
No Data
<10%
10%–14%
15%–19%
Source: Centers for Disease Control and Prevention
20%–24%
25%–29%
≥30%
Epidemiology:
Obesity Trend 2006
No Data
<10%
10%–14%
15%–19%
Source: Centers for Disease Control and Prevention
20%–24%
25%–29%
≥30%
What is the best answer?
• The following medical conditions may cause
obesity except:
•
•
•
•
A.
B.
C.
D.
Cushing’s syndrome
Hypothyroidism
PCOS
Growth hormone excess
Contributing Factors
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•
•
•
Energy imbalance: calories consumed vs. used
Environment
Genetics
Medical conditions
– Endocrine: Hypercortisolism, hypothyroidism, growth hormone
deficiency, pituitary/ hypothalamic disorders
– Genetic: Down, Prader-Willi syndromes
– Medications: Chronic glucocorticoids, neuropsychotropic
medications (atypical antipsychotics e.g. clozapine, TCAs e.g.
clomipramine)
“Classic” ABIM Question
• In the IM Boards, obesity if a risk factor for
which 2 medical conditions?
•
•
•
•
A.
B.
C.
D.
Osteoarthritis and Uterine CA
Osteoarthritis and Osteoporosis
Uterine CA and Osteoporosis
Uterine Ca and Sleep Apnea
Health Consequences
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•
•
•
•
•
•
•
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Hypertension
Metabolic syndrome
Osteoarthritis
Dyslipidemia
Type 2 diabetes
Coronary heart disease
Stroke
Gallbladder disease
Sleep apnea and respiratory problems
Some cancers (endometrial, breast, and colon)
ACP Guidelines
Pharmacologic and Surgical Management
Recommendation # 1
ALL obese patients should be counseled on
therapeutic lifestyle changes such as:
– Diet
– Exercise
– Individualized weight and health goals
ALGORITHM FOR MANAGING OBESITY
Snow V, et al. Ann Intern Med.2005;142:525-531.
Recommendation # 2
Pharmacologic treatment can be offered to
obese patients who have failed TLC. (1) Side
effects, (2) lack of long-term safety data and (3)
temporary nature of weight loss needs to be
discussed.
Recommendation # 3
Adjunctive drug therapy options include:
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–
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Sibutramine
Orlistat
Phentermine
Diethylpropion
Fluoxetine
Bupropion
Choice will depend of side effects and patient’s
tolerance
Snow V, et al. Ann Intern Med.2005;142:525-531.
Myocardial Infarction Induced by
Appetite Suppressants in Malaysia
The authors report on two otherwise healthy young women who had
myocardial infarction with acute ST-segment elevation associated with the
use of phentermine and sibutramine.
Recommendation # 4
Surgery should be considered as an option for
patients with BMI > 40 who failed TLC (with or
without adjunctive drugs) and who present with
obesity-related comorbid conditions. Long-term
side effects (e.g. possible need for re-operation,
gall bladder disease and malabsorption) should
be discussed.
Types of Bariatric Surgery
Restrictive
Vertical banded
gastroplasty
Gastric banding
Malabsorptive
Long-limb gastric
bypass
Biliopancreatic
diversion
Vertical banded gastroplasty
Biliopancreatic
diversion with
duodenal switch
Restrictive and
Malabsorptive
Roux-en-Y gastric
bypass
Biliopancreatic diversion
Figures from utdol.com
Roux-en-Y gastric bypass
Figures from utdol.com
Bariatric Surgery Complications:
Top 10
No. Complication
Restrictive
%
Combination
%
1.
Dumping (early and late)
0.3
14.6
2.
Vitamin/mineral deficiency
1.6
11.0
3.
Vomiting/nausea
8.5
2.6
4.
Staple line fracture
1.5
6.0
5.
Infection
3.1
5.3
6.
Stenosis/bowel obstruction
2.2
2.7
7.
Ulceration
1.2
1.2
8.
Bleeding
0.5
0.9
9.
Splenic injury
0.2
0.8
10.
Death (peripoeratively)
0.1
0.4
Abell TL and Minocha A. Am J Med Sci. 2006;331:214-218.
Nutritional Complications
• Macronutrient
– Protein-calorie malnutrition; S/Sx:
• Excessive weight loss (either beyond pre-determined goals
or too rapidly)
• Severe diarrhea and/or steatorrhea
• Low or diminishing visceral protein markers (i.e. albumin and
prealbumin)
• Hyperphagia
• Muscle wasting (marasmus)
• Edema (kwashiorkor)
– Fat Malabsorption
Malinowski SS. Am J Med Sci. 2006;331:219-225.
Nutritional Complications
• Micronutrient
– Vitamin B12
– Iron
– Folate
– Calcium
– Thiamine
– Fat-soluble vitamins
Another Complication
• Cholelithiasis
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–
–
–
From post-surgical weight loss not the surgery
About 50% had sludge, which may lead to cholesterol stones
Ursodiol x 6 months post-bypass effective in reduction of events
Laparoscopic cholecystectomy usually safe and effective in
symptomatic uncomplicated cholelithiasis
– Surgical treatment of choledocholithiasis may be more
complicated due to difficult access to biliary tree by ERCP
Recommendation # 5
Patient should be referred to high-volume
centers with surgeons experienced in bariatric
surgery.
Take Home Points
• Obesity is generally defined as BMI > 30
• Prevalence is growing; last year, only 4 states remain to
have obesity prevalence < 20%
• All obese patients, without exception, need counseling
for TLC (i.e. diet, exercise, individual goals)
• Pharmacologic treatment lack long-term safety data
• Bariatric surgery, while effective, may have multiple
GI, nutritional and metabolic complications
MANAGEMENT MUST BE INDIVIDUALIZED
AND THOROUGHLY DISCUSSED
WITH A MULTI-DISCIPLINARY TEAM.
Thank you and
Keep fit!