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Adult
Obesity Medicine in a Nutshell
KENNA WOOD, DO
Diplomate American Board
Of Obesity Medicine
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Disclosures
▶ I have no financial disclosures
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Purpose of this presentation
▶Provide a broad overview of the
practice of obesity medicine
▶Details on the slides can be used
as a guide
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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
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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
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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+
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https://www.cdc.gov/obesity/data/databases.html
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https://www.cdc.gov
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Weight bias
▶Check your biases at the door
▶No one deserves weight problems
▶Every patient deserves respect
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▶Food environment
▶Home
▶ Society
▶Hormones
▶Genetics
▶Sleep
What factors contribute to
obesity?▶Stress
▶Microbiome
▶Sedentary
lifestyles/sedentary jobs
▶Disability
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Food
environments
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Food environment (or lack of access to healthy foods)
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Hormones
Wait, what?!!!
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Sicat, J. Pathophysiology (Part 1) OMA presentation
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Genetics
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Genetics
▶Prader Willi
▶ Leptin deficiency
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Genetics ▶MC4R deficiency
▶And many others
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Sleep
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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
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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)
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Stress
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Intestinal
Microbiomes:
associated with obesity
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Disability
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“Eat less, move more”
is not how it worksIt is not that simple.
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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
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Definition of success
▶5-10 % total body weight loss within 6
months and maintained for at least 1 year
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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
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Diet
▶Food order matters
▶ Shukla et al. 2015
▶N=11
▶ Lower glucose &
insulin levels with
protein & veggie
before simple
carbs
Shukla et al. 2015
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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
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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
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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
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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
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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
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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
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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?
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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
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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
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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
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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
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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
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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
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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
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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!
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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)
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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
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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.”
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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
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Obesity CME
▶Obesity Medicine Association (OMA)
▶The Obesity Society (TOS)
▶Harvard Medical School
▶Columbia University
▶The Endocrine Society
▶Local CME programs: Legacy/OHSU
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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
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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
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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
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Do you have to seek ABOM
certification?
▶No, you can simply assist patients in your
practice
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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
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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
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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
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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.
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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.
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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.