obesity the symptom - about ncpa the symptom: ... generalized adaptation syndrome‐hans selye...

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Obesity the Symptom: How Community Pharmacists Can Stop the 

Biochemical Chaos!

NCPA Annual Convention Orlando 2017

Kathy M. Campbell, PharmDCEO Medicap Pharmacy Owasso

Dr Kathy Health, LLC

Disclosure

Kathy Campbell, PharmD, Medicap Pharma declares no conflicts of interest or financial interest in any product or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria.

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Learning Objectives

• Discuss the impact of nutrient deficiency on obesity.

• Explain body composition analysis and its role in health management.

• Discuss the fundamentals of an appointment‐based model.

• Discuss marketing and outreach efforts that are effective in promoting a weight loss niche.

Objectives

•Understand the role of cortisol and insulin in obesity

• List commonly prescribed pharmaceuticals contributing to obesity

•Discuss two mechanisms for nutrient deficiency

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Main Street America

Introduction

• Clinical Community Pharmacist practicing in Owasso, Oklahoma for 25 years

• Independent pharmacy owner for 17 years

• Mom to Emma and Abby for 16 years

• Wife and partner to Royce 19 years

• Morbidly Obese much of 45 years

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What causes a tornado??

• Temperature?• Pressure?• Convection?• Humidity?

What causes a hurricane?

• Temperature?• Pressure?• Convection?• Humidity?

When conditions are right.

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Consider that Obesity is the Symptom 

Like a hurricane and a tornado, obesity occurs when conditions are 

right.

AdultObesityRates by State‐1990

Stateofobesity.org

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AdultObesityRates by State‐2000

Stateofobesity.org

AdultObesityRates by State‐2010

Stateofobesity.org

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AdultObesityRates by State‐2016

Stateofobesity.org

1990 2016

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Just think…

In 1990,1 out of 10 family members was considered obese.

Today,1 out of 3 family members is considered obese.

WHAT IS GOING ON????

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Obesity is the appropriate biochemical and physiologic consequence of many cultural, 

hormonal, environmental, psychological, and nutritional influences.

Obesity is the Symptom

Obesity‐The unhealthy accumulation of body fat. Defined as a BMI>30kg/

Etiology‐Obesity is the end result of an imbalance between food eaten and energy expended, but the underlying causes are more complex.  Genetic, hormonal, and neurological influences all contribute to weight gain and loss.  In addition, some medications (e.g., tricyclic antidepressants, insulin, and sulfonylurea agents) may cause patients to gain weight. Taber’s Cyclopedic Medical Dictionary 

19th edition

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Meet Mark 54-year old male

height                                      5’10”

weight        230lbs.

Calculated BMI  32 (Obese)

Target goal weight of 180lbs.    Based on BMI

BMI 32Weight 230lbs.Height 5’10”4% body fat

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What conditions contribute to Obesity?

• Drug/chemical Toxicity• Nutrient Deficiencies (Cellular Malnourishment)• Gut Imbalance/Microbiome Disruption • Genetics• Culture

Drug/chemical Toxicity‐CORTISOL

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Generalized Adaptation Syndrome‐ Hans Selye (1907‐1982)Stress Response Involving the Nervous and Endocrine Systems

Stage 1: Alarm reaction (AR)Stage 2: Stage of resistance (SR)Stage 3: Stage of exhaustion (SE)

Generalized Adaptation Syndrome

Stage 1: Alarm Reaction (AR)

• The body recognizes the stressor and the pituitary‐adrenocortical system responds by producing the hormones essential to “flight or fight.”  In this stage, heart rate increases, blood glucose is elevated, pupils dilate, and digestion slows.

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Generalized Adaptation Syndrome

Stage 2: Stage of Resistance (SR)• The resistance or adaptive stage is when the body begins to repair the effects of the arousal.  The acute stress symptoms diminish or disappear.

• If the stress continues, the body adapts. Changes take place in order to reduce the effect of the stressor. For example, if the stressor is starvation (possibly due to malnourishment), the person might experience a reduced desire for physical activity to conserve energy, and the absorption of nutrients from food might be maximized.

Generalized Adaptation Syndrome

Stage 3: Stage of Exhaustion (SE)• At this stage, the body can no longer respond to the stress.

• Generally, this means the immune system, and the body's ability to resist disease, may be almost totally eliminated. Patients who experience long‐term stress may succumb to one or several of a great variety of diseases such as emotional disturbances, cardiovascular and renal diseases or severe infections due to their reduced immunity. 

Taber’s Cyclopedic MedicalDictionary 19th edition

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Integrativepro.com

Chemical Toxicity‐CORTISOL

CORTISONE adverse reactions• Hypertension• Osteoporosis• Peptic ulcer, IBD• Decreased carbohydrate tolerance• Negative nitrogen balance due to protein catabolism• Loss of muscle mass (sarcopenia)• Weight gain, increased appetite

“It’s just stress.”

CORTISONE ACETATE Package InsertGolden State Medical Supply, Inc.

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MalnourishmentHypoglycemiaHyperglycemiaInfectionsToxinsPain

ChildrenParentsVacationsSuccessWealthBusiness

“Every stress leaves an indelible scar, 

and the organism pays for its survival 

after a stressful situation 

by becoming a little older.”r

-Hans Selye, MD, PhD

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FOOD  IS INFORMATIONElizabeth Lipski, PhD

Chemical Toxicity‐INSULIN

• Is secreted in response to elevations of blood glucose, such as after a meal and in times of stress. (sulfonylureas)

• Controls the metabolism and cellular uptake of sugars, proteins and fats.  

• Facilitates storage of excess glucose as glycogen in the liver and prevents the breakdown of stored fats. ANABOLIC

• Suppresses sugar production (gluconeogenesis).

• Critical in times of famine.

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Chemical Toxicity‐INSULIN

• Hypertension‐anabolic effect on vasculature, hypokalemia, hypomagnesemia

• Weight gain‐anabolic effects and storage of sugar into fat

• Hypoglycemia‐sweating, dizziness, anxious, hunger, headache, irritability, shaking, fast heartbeat, weakness, fatigue, “hot flashes” 

• “fight or flight”‐TOXIC CHEMICAL IN EXCESS

ANABOLIC VS. CATABOLICINSULIN                        CORTISOL

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Chemical Toxicity‐RESISTATNCE

Resistance• a. Ability (of an organism, tissue, or cell) to withstand a destructive agent or condition such as a chemical compound, a disease agent, or an environmental stressor: antibiotic resistance; resistance to fungal diseases; drought resistance.

• b. Lack of normal response to a biologically active compound such as a hormone

What conditions contribute to Obesity?

• Drug/chemical Toxicity

• Gut Imbalance/Microbiome Disruption• Nutrient Deficiencies (Cellular Malnourishment)• Genetics• Culture

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FOOD IS THE CHEMISTRY OF LIFE

DIGESTION is the process by which food is broken down mechanically and chemically in the GI tract and converted 

into absorbable forms.

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Gut Imbalance/Microbiome Disruption 

• Caesarean Delivery‐Association between caesarean section and childhood obesity: a systematic review and meta‐analysis Obes Rev. 2015 Apr;16(4):295‐303. doi: 10.1111/obr.12267. Epub 2015 Mar 5

• Antibiotics, anti‐bacterial products‐Antibiotics in early life and obesity. Nat Rev Endocrinol. 2015 Mar; 11(3): 182–190.

• Low Diversity‐Potential probiotic Bifidobacterium animalis ssp. lactis 420 prevents weight gain and glucose intolerance in diet‐induced obese mice. Benef Microbes. 2014 Dec;5(4):437‐45. doi: 10.3920/BM2014.0014.

• “Leaky Gut” Zonulin, a newly discovered modulator of intestinal permeability, and its expression in coeliac disease. Lancet. 2000 Apr 29;355(9214):1518‐9

• Bacterial Overgrowth/Imbalance‐ “Diet Soda, Sugar, Gluten”

• Achlorhydria

Role of Gastric Acid in Digestion

• Key in protein digestion by activating pepsinogen to pepsin.

• Bio‐transforms nutrients into absorbable forms.

(iron, b‐12, Zn, Ca, Mg)

• Maintains a sterile environment in the stomach, prevents bacterial overgrowth

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Gut Imbalance/Microbiome Disruption

ACHLORHYDRIA‐the absence of free hydrochloric acid in the stomach.

• Age‐related‐begins in 40’s• Weight loss Surgery (Roux‐N‐Y gastric bypass, Gastric Sleeve, etc.)

• Drug‐induced‐• Proton‐pump inhibitors Inhibitors‐Omeprazole (Losec 1988, Prilosec, otc 2003)

• Histamine antagonists (Cimetidine, Tagamet 1976, otc 1995)

• Anticholinergics (diphenhydramine, certrizine, Oxybutynin, etc.)

YOU ARE WHAT YOU EAT…

AND ABSORB

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Xie Y, Bowe B, Li T, et al Risk of death among users of Proton Pump Inhibitors: a longitudinal observational cohort study of United States veterans BMJ Open 2017;7:e015735. doi: 10.1136/bmjopen-2016-015735

Conclusions- The results suggest excess risk of death among PPI users; risk is also increased among those without gastrointestinal conditions and with prolonged duration of use. Limiting PPI use and duration to instances where it is medically indicated may be warranted

What conditions contribute to Obesity?

• Drug/chemical Toxicity• Gut Imbalance/Microbiome Disruption • Nutrient Deficiencies(Cellular Malnourishment)

• Genetics• Culture

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FOOD IS THE CHEMISTRY OF LIFE

WE ARE A PROFOUNDLY      

“MIS‐NOURISHED,” IF NOT  

MALNOURISHED, SOCIETY

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Nutrient DeficiencyCELLULAR MALNOURISHMENT

Cultural Shifts in Dietary Habits• World War II‐Prior and Post

• Low‐Fat (High Sugar) Approach• 1980’s Minivan• Loss of Food Knowledge and

Basic Cooking Skills

Nutrient DeficiencyCELLULAR MALNOURISHMENT

Sugar Industry and Coronary Heart Disease Research, A Historical Analysis of Internal Industry DocumentsKearns et al, JAMA Intern Med. 2016;176(11):1680‐1685. doi:10.1001/jamainternmed.2016.5394

“Policymaking committees should consider giving less weight to food industry–funded studies and include mechanistic and animal studies as well as studies appraising the effect of added sugars on multiple CHD biomarkers and disease development.”

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Nutrient DeficiencyCELLULAR MALNOURISHMENT

“Eat less” is WRONG…

Must eat a heck of a lot of the right stuff!!!

Nutrient DeficiencyCELLULAR MALNOURISHMENT

• VITAMIN D

• IRON

• OMEGA 3 FATS

• B‐VITAMINS

• PROTEIN

• CO‐Q 10

• MAGNESIUM, ZINC

HOW CAN THE MOST OBESE BE MALNOURISHED?

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CLINICAL-Case Study CM

CM is a 23-year old female who began weight loss program after her parents had participated and encouraged her to as well.

As part of her journey, she decided to begin a relationship with a physician in an effort to “get healthy.”

At pharmacist’s recommendation, she requested specific laboratory testing.

CLINICAL‐Case Study CM

Physician commented in patient portal that he

“ …was reluctant to order these laboratory tests for this 23-year old, healthy, obese female.”

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455 lbs.

Beginning weight 8/20/2016

CLINICAL-Case Study CM

Significant Laboratory findings 10‐6‐2016

Pre‐Albumin 15.0 (18‐37 mg/dl)

TIBC 409 (280‐380ug/dl)

B‐12 289 (200‐1000ug/dl)

Insulin 95.5 (6‐27mU/L)????

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What may be going on…

• Lack of adequate nutrients from food and lifestyle. (Standard American Diet and lower socio‐economic status)

• Basal Metabolic Rate of 2300kcal (High muscle mass due to weight and Insulin)

• Reduced absorption of nutrients secondary to low acid• Altered digestion due to chronic stress (cortisol)• Lack of nutrients secondary to bacterial overgrowth robbing nutrients• Low beneficial Bacteria, Excessive pathogenic bacteria• Hyperinsulinemia

What may be going on…

• Gluconeogenesis, excessive hunger, chronic hypoglycemia secondary to hyperinsulinemia/insulin resistance/chronic stress

• Fatigue as compensatory mechanism and due to chronic nutrient deficit. 

• Chronic stress secondary to poor self‐image/internal dialog, change in family support system,  toxic societal commentary due to weighing 455lbs and adverse childhood experiences (ACE).

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What conditions contribute to Obesity?

• Drug/chemical Toxicity• Gut Imbalance/Microbiome Disruption • Nutrient Deficiencies (Cellular Malnourishment)

• Genetics• Culture

HUMANS ARE 

BIOCHEMICALLY UNIQUE

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GENETICS in OBESITY

• Epigenetics is the ‘turning on and off’ of genes due to external or environmental factors.

• Nutrigenomics is the study of how the genome and diet interact to influence human health and disease. 

• Opportunity to customize diet and lifestyle based on genome

The role of genetics appears to be between 40 and 80%.        van Dijk et al. Clinical Epigenetics (2015)7:66 DOI 10.1186/s13148‐015‐0101‐5

Genetics loads the gun,

Lifestyle (culture) pulls the trigger.

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What conditions contribute to Obesity?

• Drug/chemical Toxicity• Gut Imbalance/Microbiome Disruption • Nutrient Deficiencies (Cellular Malnourishment)

• Genetics

• Culture

Culture is the characteristics and knowledge of a

particular group of people, defined by everything from language, religion, cuisine,

social habits, music and arts.

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Consider The Culture Of An Olympian

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Health“...[S]tate of complete physical, mental, and social well-being and not merely the absence of

disease, or infirmity”(W.H.O. 1946).

CULTURE PRODUCES HEALTH

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Blue Zone Project

What HEALTH is your CULTURE producing?

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Integrativepro.com

RECOVERY STAGE??Rest and SleepConnectionContribution

FUN

How does a community pharmacist help?

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Obesity is the appropriate biochemical and physiologic consequence of many cultural, 

hormonal, environmental, psychological, and nutritional influences.

Obesity is the Symptom

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Components of a Pharmacy‐based Weight Loss Program‐CLINICAL

•Detoxification•Nutrient/Medication Evaluation and Assessment

•Body Composition Analysis

•Culture Analysis and Design•Active Life•Customized Eating Plan 

RESOURCES

• IFM.org   The Institute of Functional Medicine

• 23andme.com  

• Inbody Body Composition Scale Hilary@inbodyusa.com

• Bluezones.com• DrKathysays.com• DrKathyweightloss.com

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Kathy M. Campbell, PharmDCEO DrKathy Health LLC, Medicap Pharmacy Owasso

kathy@drkathysays.com918‐992‐4FIT (348)