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Medical Management of Obesity
Nirav Rana, MD
Bariatric Surgeon
Bariatrx
Jeanne M. Ferrante, MD, MPH
Associate Professor
Robert Wood Johnson Medical School
Family Medicine and Community Health
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Disclosures
Dr. Ferrante has received grant/research support from Horizon Health Innovations within the past 12 months.
Dr. Rana has nothing to disclose relevant to this presentation.
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Objectives
Identify patients who would benefit from surgical intervention for the treatment of obesity and its associated co-morbid conditions.
Discuss the clinical benefits of bariatric surgery
Discuss the long term management of patients after bariatric surgery
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Trends in Obesity Prevalence 1976-2010
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Determining Treatment
BMI Treatment
25-26.9 Healthy Lifestyle
27-29.9 Healthy Lifestyle; Medications if additional risk factors
30-39.9 Intensive Behavioral Therapy; Medications; Surgery if BMI > 35 and co-morbidities
> 40 Intensive Behavioral Therapy; Medications; Surgery
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Treatment Options
Correct underlying metabolic problems Diet, exercise, behavioral therapy Medications
Optimize current medicationAnti-obesity medications
Bariatric Surgery
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Diet and Exercise
Low calorie diet: 500-1000 kcal/d Women: 1200-1500 kcal/d Men: 1500-1800 kcal/d
Very low calorie diet: 800 calories or less 3-6 months (BMI > 50) Before surgery or long term wt-loss program
Daily aerobic exercise ~ 60 minutes Weight training after aerobic goals met
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Low-carb vs. Low-fat diet
Doesn’t matter what kind of diet Weight loss similar (11% at 6 and 12 months,
7% at 24 months) Decrease in blood pressures similar Decrease LDL and TG similar Increase HDL (20%) in low carb
Weight loss maintenance low glycemic index, higher protein diet
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Low Glycemic Index http://www.the-gi-diet.org/lowgifoods/ Fruits- cherries, plums, grapefruit,
peaches, prunes, apples, pears, grapes, oranges, strawberries- avoid watermelon
Most vegetables except beets, pumpkin, parsnips
Wheat pasta, egg fettuccini, spaghetti, brown rice, white long grain rice
Avoid white bread, bagel, french baguette
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Behavioral Modification
Self-monitoring Goal setting Stimulus control
activities, cues, circumstances, and practices that favor nonmeal eating and snacking
Eat most meals at home Drink 500 ml water before each meal Optimal sleep (7-8 hours)
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Preventive Counseling Codes
Obesity screening and and dietary counseling (V65.3)
Exercise counseling (V65.41) CPT
99401 (15 min)99402 (30 min)99403 (45 min)99404 (60 min)
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Medicare Coverage for Obesity Intensive Behavioral Therapy (G0447)
Primary care physician or NP/PA/certified
clinical nurse specialist- face-face x 15 minsUp to 22 visits over 12 months
Every 1 week (Month 1), every 2 weeks (Months 2-6) If loses 3 kg, continue every 4 weeks (Months 7-12)
If not, can reassess after 6 monhts5A’s: Assess, Advise, Agree, Assist, ArrangeNot separately payable with another encounter
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Medicare CodesBMI ICD-9 ICD-10
30-30.9 V85.30 Z68.30
31-31.9 V85.31 Z68.31
: : :
39-39.9 V85.39 Z68.39
40-44.9 V85.41 Z68.41
45-49.9 V85.42 Z68.42
50-59.9 V85.43 Z68.43
60-69.9 V85.44 Z68.44
> 70 V85.45 Z68.45
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5 A’s ExamplesAssess “Tell me what you typically eat for breakfast.”
“How much activity do you do on a typical day?”
Advise “Keep a food diary and decrease your calories to 1200 a day.”
Agree “Would you agree to a low carb diet?”
Assist “Here’s a handout on low glycemic index foods.”
Arrange “Come back to see me in 1 week so we can see how you’re doing.”“Let’s schedule you to see a nutritionist.”
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Medications
Optimize current medications Anti-obesity drugs
Short term: benzphetamine, diethylproprion, phendimetrazine, phentermine
Long term Inhibits fat absorption: orlistat (Xenical, Alli) Decrease appetite
phentermine/topiramate (Qsymia) lorcaserin (Belviq)
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Drug AlternativesAntidiabetic agentsInsulin; meglitinides; sulfonylureas (glyburide, glipizide); thiazolidinediones
Acarbose (Precose); exenatide (Byetta); glimepiride (Amaryl); metformin (Glucophage); miglitol (Glyset); pramlintide (Symlin)
Neurologic agentsAnticonvulsants (valproic acid [Depakene], gabapentin [Neurontin], carbamazepine [Tegretol]); lithium
Lamotrigine (Lamictal); topiramate (Topamax); zonisamide (Zonegran)
Optimize Medications
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Drug Alternatives
Psychiatric agentsAntipsychotics (clozapine [Clozaril], olanzapine [Zyprexa], and risperidone [Risperdal])
Monoamine oxidase inhibitors (e.g., phenelzine [Nardil])
Some SSRIs (paroxetine [Paxil])
Tricyclic antidepressants (amitriptyline, imipramine nortriptyline)
Aripiprazole (Abilify); ziprasidone (Geodon)
Tranylcypromine (Parnate)
Bupropion (Wellbutrin); venlafaxine (Effexor); fluoxetine (Prozac)
Desipramine (Norpramin); protriptyline
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Drug AlternativesBlood pressure agentsAlpha-adrenergic blockers
Beta-adrenergic blockers (especially propranolol)
Doxazosin (Cardura)
Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers; calcium-channel blockers; selective beta blockers
Othercorticosteroids Acetaminophen; nonsteroidal
anti-inflammatory drugs
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Medications
Orlistat (Xenical, Alli)Lipase inhibitor: inhibits fat absorption120 mg tid during or up to 1 hour after mealSide effects: flatulence, oily stool, diarrhea,
and stool incontinence Reduces absorption of fat-soluble vitamins
and beta-carotene: take vitamins 2 hours before or 1 hour after meal
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Medications
Phentermine-topiramate (Qsymia)Low dose: 7.5 mg/46 mg 8.0% weight lossHigh dose: 15 mg/92 mg 10.5% weight lossSide effects: increased heart rate, palpitations,
drowsiness, paresthesias, memory loss, confusion
Contraindicated in pregnancy (orofacial cleft)
and recent/unstable CAD or CVDRisk evaluation and mitigation strategy (REMS)
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Medications
Lorcaserin (Belviq)10 mg bidselectively activates 5-HT2C receptors on
anorexigenic neurons in the hypothalamus decreases eating and promotes satiety
4.5% - 5.8% weight lossSide effects: headache, dizziness, fatigue,
drowsiness, nausea, dry mouth, constipationContraindicated pregnancy, caution CHF
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Bariatric Surgery
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Number of Bariatric Surgeries Performed
American Society for Metabolic and Bariatric Surgery
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Indications
• BMI >40 kg/m2 or BMI >35 kg/m2 with an associated medical comorbidity worsened by obesity
• Failed dietary therapy• Psychiatrically stable without alcohol
dependence or illegal drug use• Knowledgeable about the operation and its
sequela• Motivated individual• Medical problems not precluding probable
survival from surgery
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Obesity Related Conditions
• Diabetes• Hypertension• Hyperlipidemia• Respiratory disease • Sleep apnea• Depression• Menstrual irregularity• Cardiovascular disease• Urinary stress
incontinence• Asthma/pulmonary
disorder• Gastroesophageal reflux
disease (GERD)
• Degenerative joint disease (DJD)
• Congestive heart failure • Gallstones• Coronary heart disease • Stroke• Osteoarthritis• Cancer• Amenorrhea• Polycystic ovary
syndrome• Infertility• Dysmenorrhea
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Preop Evaluation
• Nutritionist visits• Psychological evaluation• Exercise Physiology evaluation• EGD with biopsies for H. pylori• UGI series• IVC filter placement• Cardiopulmonary evaluation• Routine bloodwork• Vitamin levels
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Silicone band
Encircles proximal stomach
Purely restrictive procedure
Adjustable Gastric Band
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Roux-en-Y Gastric Bypass
20 to 30 cc pouch
Disconnected
pouch-stomach
~ 1 cm diameter
outlet
Intestinal bypass of
either 75 to 150 cm
+/- Cholecystectomy
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The Foregut TheoryExclusion of Duodenum from transit of nutrientsprevents secretion of signal that promotesinsulin resistance and DM type 2
Rubino F. Annals of Surgery • Vol 244, Nov 2006
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A gastric tube of 60 to 120mL is created
Induces weight loss by 2 mechanisms:1) Mechanical restriction2) Hormonal modification
Sleeve Gastrectomy
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%EWL 57 %New GERD 21 % (3% preop)Leak 4.9 %Mortality 0
Himpens J. Ann Surg 252: 319–324 2010
n=53, av. follow-up 6 yrs
Sleeve Gastrectomy Long Term results
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Tice J. Am J Med. Vol 121, 10. 2008
Resolution
%
Preoperative Morbidity
■ Bypass
■ Band
DM DyslipidemiaHTN OSA
908070605040302010
Bypass versus Band
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Band%
Sleeve%
Bypass%
%EWL 49 57 63
DMRemission
47 63 83
Mortality 0.2 1 0.6
Morbidity 33 9 7
Vit Def 0 32 58
Comparison of Bariatric Surgery
Buchwald, H. JAMA 2004
Meta Analysis
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Bariatric Surgery versus Intensive Medical Therapy
Schauer P, NEJM 2012
Change in BMI
Intensive medical therapy
Gastric Bypass
Gastric Sleeve
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Long-Term Management after Bariatric Surgery
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Long-term complications
Short-term complications: stomal stenosis, incisional hernia, marginal ulcer, constipation
Cholelithiasis Dumping syndrome: abdominal pain, N/V,
diarrhea, tachycardia, flushing, dizziness Vomiting/GERD from pouch distention
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Long-term complications
Nutritional deficiencies: Calcium/Vit D, iron/folate, B vitamins, protein, potassium, Mg
Panniculitis: antibiotics, skin hygiene, surgical excision
Malabsorption of oral meds: avoid extended-release meds- use rapid release or oral solutions
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Laboratory Testing
Follow-up period Laboratory TestsEvery 3 months x 1 year CBC, glucose, creatinineEvery 6 months x 1 year Liver function tests,
protein and albumin, iron studies, vitamin B12/folate, calcium, Mg, vitamin D, PTH if hypercalcemic
Every year afterwards All of above
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Diet
Adequate protein: 80 g per day Eat slowly, chew thoroughly, cut foods into
small pieces Avoid fluids 15-30 minutes before, during
and after meals Avoid carbonated drinks/using straws Avoid very dry foods, breads, fibrous
vegetables
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SupplementsSupplement Restrictive Malabsorptive
Calcium citrate
1,500 mg/day 1,500-2,000 mg/day
Elemental iron
--------- 18 – 27 mg/day
Multivitamin with minerals
One/day Two/day
Vitamin B12 --------- 350 mcg/day po500 mcg/day SL1000 mcg IM monthly
Vitamin D 400 to 800 IU/day 2,000 IU daily
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Pregnancy after Bariatric Surgery
Wait 12-24 months Monitor nutritional status and deficiences Thoroughly evaluate GI symptoms Women with dumping syndrome may not
tolerate 50-g glucose test Avoid NSAIDs during postpartum period Should not affect labor and delivery
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