adult obesity medicine in a nutshell - peacehealth · 2019-09-25 · sedentary jobs/lives. image...

Adult

Obesity Medicine in a Nutshell

KENNA WOOD, DO

Diplomate American Board

Of Obesity Medicine

kwood3@peacehealth.org

Disclosures

▶ I have no financial disclosures

Purpose of this presentation

▶Provide a broad overview of the

practice of obesity medicine

▶Details on the slides can be used

as a guide

ObjectivesUnderstand why obesity is considered a disease with multiple etiologies

Understand how to communicate with patients about their weight and secondary conditions

Understand the fundamentals of discussing physical activity and various diet options to treat obesity

Understand the importance of sleep in affecting weight

Understand the medications that affect weight

Review the laws affecting controlled medications for bariatric practice

Review sources of additional continuing medical education on obesity medicine

Why is obesity CME needed?

▶There is an epidemic

▶Not currently taught in schools

▶Very few providers know how to treat obesity

▶Prevent obesity in children/future adults

Definitions

▶Overweight BMI 25.0-29.9

▶Class 1 obesity BMI 30.0-34.9

▶Class 2 obesity BMI 35.0-39.9

▶Class 3 obesity BMI 40.0+

https://www.cdc.gov/obesity/data/databases.html

https://www.cdc.gov

Weight bias

▶Check your biases at the door

▶No one deserves weight problems

▶Every patient deserves respect

▶Food environment

▶Home

▶ Society

▶Hormones

▶Genetics

▶Sleep

What factors contribute to

obesity?▶Stress

▶Microbiome

▶Sedentary

lifestyles/sedentary jobs

▶Disability

Food

environments

Food environment (or lack of access to healthy foods)

Hormones

Wait, what?!!!

Sicat, J. Pathophysiology (Part 1) OMA presentation

Genetics

Genetics

▶Prader Willi

▶ Leptin deficiency

Genetics ▶MC4R deficiency

▶And many others

Sleep

Evidence▶ Sleep loss is associated with obesity

▶ Hasler et al. (2004): prospective, N~500, followed 13 years

▶ Lower duration of sleep lead to higher BMI at

end of study

Evidence ▶Wisconsin Sleep Study, Taheri et al. Sleep 2004. N=1024.

▶Adults with 7.7 hrs sleep had the lowest BMI

▶With less sleep, lower leptin levels, & higher ghrelin levels

▶ Reproduced 2 additional studies (n=12 and n=740)

Stress

Intestinal

Microbiomes:

associated with obesity

Sedentary jobs/lives

Disability

“Eat less, move more”

is not how it worksIt is not that simple.

How do you get started?

● Ask permission to discuss weight● Discuss:

● Diet● Exercise● Sleep/screen for sleep apnea● Review medications ● Determine if medications that control hunger

are appropriate to start● Determine if patient is a candidate for

bariatric surgery

Definition of success

▶5-10 % total body weight loss within 6

months and maintained for at least 1 year

Diet

▶Start with simple changes:

▶Cut down/eliminate sugar sweetened

beverages & ALL soda

▶ Increase vegetable intake

▶Consider meal replacements as an option

▶Use small plates

▶ Food order matters

Diet

▶Food order matters

▶ Shukla et al. 2015

▶N=11

▶ Lower glucose &

insulin levels with

protein & veggie

before simple

carbs

Shukla et al. 2015

Diet ▶Primary diets used for weight loss

▶Plant based diet

▶ Low carbohydrate diets (high protein or high

healthy fat/moderate protein)

▶ How many grams of carbs?

▶ What about patients with CKD, gout, renal stones, gallstones?

▶Mediterranean diet

Mediterranean diet VS Low Fat

Diet▶ PREDIMED- Primary Prevention of CVD with a Mediterranean Diet Supplemented with EVOO

or nuts

▶ Parallel group, multi-center, RCT

▶ N=7447

▶ High risk for CVD

▶ Energy unrestricted Mediterranean diet supplemented with EVOO

▶ Energy unrestricted Mediterranean diet supplemented with nuts

▶ Control group: low–fat (high carb) diet

▶Mediterranean diet groups associated with lower risk of major CV events over 5 years than

low fat diet, relative difference of 30%

NEJM 2018 PREDIMED

A to Z Weight Loss Study

▶Comparison of the Atkins, Zone, Ornish, and Learn

Diets, 2007, N=311, 1 year trial

▶Weight loss significantly better in Atkins diet

compared to Zone diet

▶No significant statistical difference between weight

loss in Zone, Ornish, and LEARN diets

▶ Atkins (< 20g carb x 3mo then <50g carb)

▶ Zone (40% carb, 30% prot, 30% fat)

▶ LEARN (low fat, high carb, based on national guidelines)

▶ Ornish (very high carb, <10% fat)Gardner et al. 2007

Weight loss with a Low-carbohydrate,

Mediterranean, or Low Fat Diet

▶2008, N=322, 2 year trial

▶ Low fat, restricted calorie (AHA guidelines)

▶Mediterranean, restricted calorie

▶ Low-carb, non-restricted calorie

▶Low carbohydrate & Mediterranean diets may be

effective alternatives to low fat diets

▶Mediterranean diet: more favorable effects on

glycemic control

▶ Low carb diet: more favorable effects on lipidsShai et al. 2008

Fasting

▶ Intermittent fasting

▶Daily fasting

▶Alternate day fasting

▶Eating only within an 8 hour window each

day

▶What can you eat/drink during fasting?

▶Must adjust insulin and oral anti-hyperglycemic

medications for fasting

Exercise

▶General health: 150 minutes per week

▶Do they need clearance first?

▶Start from where they are now

▶Physical therapy

▶Pulmonary rehab

▶Cardiac rehab

▶Armchair exercises

▶Pool exercises

Sleep

▶ Insomnia

▶Primary or secondary causes

▶Referral, if appropriate

▶Obstructive or central sleep apnea

▶ Screen

▶ If already diagnosed:

▶ Are they using appropriate therapy?

▶ Is their equipment working well?

Medications that can cause

weight gain:● Cardiovascular:

● some BB (propranolol, atenolol, metoprolol)

● Diabetes: ● insulin, sulfonylureas,

thiazolidinediones, meglitinides● Hormones:

● glucocorticoids, estrogens, progestins might (injectable & implantable)

● Anti-seizure: ● carbamazepine, gabapentin,

valproate● Anti-depressants:

● some TCAs (ami/doxe/imipramine)

● some SSRIs (paroxetine), mirtazapine.

● Other TCAs, SSRIs & SNRIs may also have affects

● Mood stabilizers: ● gabapentin, lithium, valproate,

vigabatrin, carbamazepine● Migraine medications:

● amitriptyline, gabapentin, paroxetine, valproic acid, some BB

● Antipsychotics: ● clozapine, olanzapine, zotepine

(substantial), quetiapine, risperidone, lithium

● Possible but less likely: aripiprazole, haloperidol, lurasidone, ziprasidone

● Hypnotics: ● diphenhydramine

Medications that can cause

weight loss:

● Diabetes: ● metformin, GLP-1

agonists, SGLT-2 inhibitors, alpha glucosidase inhibitors

● Hormones: testosterone might

● Anti-seizure:

● lamotrigine, topiramate, zonisamide

● Antidepressants: bupropion

● Mood stabilizers: lamotrigine

● Migraine: topiramate

Medications that are used for

weight loss:● Metformin

● Phentermine, phendimetrazine, diethylpropion

● Topiramate

● Qsymia(phentermine/topiramate)

● Belviq (lorcaserin)

● Naltrexone/bupropion (Contrave)

● Saxenda (GLP-1 agonist)

● Orlistat

Is bariatric surgery

appropriate?▶National Institutes of Health (NIH) established criteria for

bariatric surgery in 1992 and are still the most widely

used:

▶ BMI 30+ with obesity related comorbidity (gastric

band only)

▶ BMI 35-39.9 with a high risk comorbidity

▶ BMI >= 40

https://www.niddk.nih.gov/health-information/weight-management/bariatric-surgery/potential-candidates

Is bariatric surgery

appropriate?▶ASMBS updated position statement on bariatric surgery

in class 1 obesity- Aug 2018

▶For patients with BMI 30 to 35 kg/m2 and obesity-related comorbidities

who do not achieve substantial, durable weight loss and co-morbidity

improvement with reasonable nonsurgical methods, bariatric surgery

should be offered as an option for suitable individuals. In this population,

surgical intervention should be considered after failure of nonsurgical

treatments. Particularly given the presence of high-quality data in

patients with type 2 diabetes, bariatric and metabolic surgery should be

strongly considered for patients with BMI 30 to 35 kg/m2 and type 2

diabetes.

https://www.niddk.nih.gov/health-information/weight-management/bariatric-surgery/potential-candidates

How long do you treat

overweight/obesity?

How long would you treat any other chronic

diagnosis once it is finally under control?

○ Forever, if needed since it will be a long-term problem

○ Obesity is a chronic disease

Medications: who is a candidate

to treat with medications?

● Not everyone

○ BMI 27.1-29.9 with a

comorbidity

○ BMI 30.0+ with/

without a

comorbidity

Laws for writing controlled weight-

loss medications

● More limited prescribing than opioids

● i.e. more rules

● Oregon Medical Board, Chapter 847, Division 15

GENERAL LICENSING RULES, RELATING TO CONTROLLED SUBSTANCES ○ 847-015-0010 Schedule III or IV Controlled Substances — Bariatrics Practice

○ Statutory/Other Authority: ORS 677.265

● Laws are different by state. Know your state’s

laws!

Rules posted on OMB website:

● Must prescribe in accordance with FDA product guidelines in effect

● Must co-prescribe caloric reduction, behavior modification, and exercise, provided that all of the following conditions are met:

○ Thoroughly review prior treatments (yours and others) to determine if the following conditions exist:

■ BMI >30 or■ BMI >27 & weight threatens health (co-

morbidity)

Rules posted on OMB website:

○ Licensee obtains thorough history, thorough physical exam, rules out contraindications to use of controlled substance. (Get an EKG!)

● To continue Rx beyond 3 months requires documentation

○ Average 2 lb/mo weight loss during active weight reduction treatment

○ Goal weight maintenance once maintaining weight only

Copied from OMB Webpage:

▶Violations of this rule constitute

“Unprofessional Conduct as the term is

used in ORS 677.188(4)(a), (b), or (c),

whether or not actual injury to a patient is

established.”

Helpful hints to avoid insurance

problems● Don’t link any off-label medications to the diagnosis of

obesity/overweight unless you want to see the Rx

denied by insurance

● Don’t list “overweight” or “obesity” as the primary

diagnosis

● Primary code should be an associated and/or

secondary diagnosis (i.e. PCOS, OSA)

○ Medicare does cover obesity as a primary diagnosis

but requires very specific documentation

Obesity CME

▶Obesity Medicine Association (OMA)

▶The Obesity Society (TOS)

▶Harvard Medical School

▶Columbia University

▶The Endocrine Society

▶Local CME programs: Legacy/OHSU

American Board of Obesity

Medicine (ABOM) Certification▶Fellowship pathway

▶Completion of on-site 500+ hours of obesity or

obesity-related conditions

▶CME pathway

▶Minimum 60 credits CME on topics of obesity (AOA

cat 1-A, AMA PRA cat 1)

▶30 must be earned through attendance at

specific sites; other 30 can be earned in

attendance or online CME

▶This pathway may end in the next few years

Adult fellowships ▶Boston University School of Medicine/ Boston Medical Center, Boston,

MA

▶Geisinger Medical Center, Danville, PA

▶Harvard Medical School / Massachusetts General Hospital, Boston, MA

▶University of Texas McGovern Medical School, Houston, TX

▶New York-Presbyterian Hospital/Weill Cornell Medical Center, New York,

NY

▶Wake Forest Baptist Health, Winston-Salem, NC

▶New York University Langone Medical Center, New York, NY

20 new programs to open in 2020

Pediatric Fellowships

▶University of Tennessee Health Science Center, Memphis, TN

▶Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE

▶Nationwide Children’s Hospital, Columbus, OH

Do you have to seek ABOM

certification?

▶No, you can simply assist patients in your

practice

EDUCATIONAL RESOURCES FOR HEALTH CARE PROFESSIONALS

▶ Use these resources to further your education – and your staff’s and patients’ education –about clinical obesity treatment.

Patient Resources

● Obesity Action Coalition (OAC)

○ www.obesityaction.org

Physician and Health Care Professional Resources

● Obesity Medicine Association (OMA)○ www.obesitymedicine.org

● Obesity Algorithm®

○ www.obesityalgorithm.org● American Board of Obesity Medicine

(ABOM)○ www.abom.org

● Obesity Treatment Foundation○ www.obesitytreatmentfoundation.org

● Academy of Nutrition and Dietetics ○ www.eatright.org

● American Association of Clinical Endocrinologists○ www.aace.org

EDUCATIONAL RESOURCES FOR HEALTH CARE PROFESSIONALS● American Cancer Society

○ www.cancer.org

● American College of Sports

Medicine

○ www.acsm.org

● American Diabetes Association

○ www.diabetes.org

● American Heart Association

○ www.heart.org

● American Society for

Metabolic & Bariatric Surgery

○ www.asmbs.org

● Canadian Obesity Network

○ www.obesitynetwork.ca

● Hormone Health Network

○ www.hormone.org

● Mental Health America

○ www.mentalhealthameric

a.org

EDUCATIONAL RESOURCES FOR HEALTH CARE PROFESSIONALS

● National Association of Anorexia Nervosa and Associated Disorders○ www.anad.org

● National Cancer Institute○ www.cancer.gov

● National Eating Disorders Association○ www.nationaleatingdisorders.org

● National Institute of Diabetes and Digestiveand Kidney Diseases○ www.niddk.nih.gov

● National Heart, Lung, and Blood Institute○ www.nhlbi.nih.gov

● The Endocrine Society○ www.endocrine.org

● The Obesity Society○ www.obesity.org

● STOP Obesity Alliance○ www.stopobesityalliance.org

● World Obesity Federation○ www.worldobesity.org

References

● Centers for Disease Control (2015), Obesity trends among US

Adults. Retrieved from

https://www.cdc.gov/obesity/data/databases.html

● Estruch, R., Ross, E., & Salas-Salvado, J. (2018). Primary

prevention of cardiovascular disease with a Mediterranean diet

supplemented with extra-virgin olive oil or nuts. New England

Journal of Medicine, 378(25), e34(1)-e34(14).

● Gardner et al. (2007). Comparison of the Atkins, Zone, Ornish,

and LEARN Diets. The Journal of the American Medical Association

, 279 (9), 969-978.

References

● Hasler, G. et al. (2004). The association between short sleep

duration and obesity in young adults: a 13 year prospective study.

Sleep. 27(4), 661-6.

● Lenard NR (2008). Central and peripheral regulation of food

intake and physical activity: pathways and genes. Obesity, 16(3),

Figure 4.

● Shai et al. (2008). Weight Loss with a low-carbohydrate,

Mediterranean, or low-fat diet. New England Journal of

Medicine, 359(3), 229-241.

References

● Sicat, J. (2017). Pathophysiology (Part 1) Presentation for

Obesity Medicine Association. Image slide 29.

● Shukla, A. et al. (2015). Food Order Has a Significant Impact on

Postprandial Glucose and Insulin Levels. Diabetes Care, 38, e98-

99.

● Taheri, S. et al. (2004). Short sleep duration is associated with

reduced leptin, elevated ghrelin, and increased body mass index.

PLoS Medicine, 1(3), e62.