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
•
•
•
•
•
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
•
•
•
•
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
•
•
•
•
•
•
•
•
•
•
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:
–
–
–
–
–
–
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
–
–
–
–
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!