Prevalence of Obesity 2011-2012 Obesity prevalence: Adults 34.9% - - PDF document

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Robert Baron, MD, MS

CURRENT APPROACHES FOR OBESITY: Diet, Exercise, Medications, Surgery

Robert B. Baron MD MS Professor of Medicine Associate Dean for GME and CME Founding Director, UCSF Weight Management Program Declaration of full disclosure: No conflict of interest

Prevalence of Obesity 2011-2012

• Obesity prevalence:
• Adults 34.9%
• Youth 16.9%
• No change since 2003-2004

Ogden Cl, JAMA 2014

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Robert Baron, MD, MS

Ogden, JAMA 2014

Obesity Disparities: Example: BMI >35

• Women, 40-59: 19.1%
• White: 16.9%, Black: 30.4%, Asian 4.6%,

Hispanic 25.5%

• Men, 40-59: 12.2%
• White: 12.8%, Black: 15.7%, Asian 0,

Hispanic 8.7%

15%–<20% 20%–<25% 25%–<30% 30%–<35% ≥35%

Prevalence of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2013

CA MT ID NV UT AZ NM WY WA OR CO NE ND SD TX OK KS IA MN AR MO LA MI IN KY IL OH TN MS AL WI PA WV SC VA NC GA FL NY VT ME HI AK NH MA RI CT NJ DE MD DC PR GUAM

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Robert Baron, MD, MS

For a 40 yo woman, with normal BP, lipids, and FBS which BMI is associated with the lowest all- cause mortality?

• 1. 18
• 2. 24
• 3. 28
• 4. 34
• 5. 38

CLASSIFICATION OF OVERWEIGHT AND OBESITY BY BMI

Obesity Class BMI (kg/m2) Underweight <18.5 Normal 18.5 – 24.9 Overweight 25.0 – 29.9 Obesity I 30.0 – 34.9 II 35.0 – 39.9 Extreme Obesity III >40

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Robert Baron, MD, MS

Flegal, JAMA, 2005

BMI AND MORTALITY: Overall

Combined NHANES I, II, and III data set BMI 25-59 y 60-69 y ≥70 y <18.5 1.38 2.30 1.69 18.5-<25 1.00 1.00 1.00 25 to <30 0.83 0.95 0.91 30 to <35 1.20 1.13 1.03 ≥35 1.83 1.63 1.17

Flegal, JAMA, 2013

MORTALITY AND OBESITY

Meta-analysis of 97 studies of 2.8M people, 270,000 deaths BMI HR

Below 25 (Normal) 1.0 25-30 (Overweight) 0.94 Above 30 (Obese) 1.18 *** 30-35 (Grade 1 Obesity) 0.95 Above 35 (Grade 2/3 Obesity) 1.29

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Robert Baron, MD, MS

For a 40 yo woman, with normal BP, lipids, and FBS which BMI is associated with the lowest all- cause mortality?

• 1. 18
• 2. 24
• 3. 28
• 4. 34
• 5. 38

Epidemic of Inactivity

60% US adults don’t exercise regularly 25% are sedentary

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Robert Baron, MD, MS

Shaw, Cochrane, 2006

EXERCISE FOR OBESITY

Meta-analysis of 43 RCTs: 3476 participants

• Exercise plus diet vs diet alone

– -1.1 kg

• Increased intensity of exercise

– -1.5 kg

• Exercise without weight loss

– Reduced: BP, triglycerides, blood sugar

Wei, JAMA 1999

FITNESS AND MORTALITY Aerobics Center Longitudinal Study

CV death (RR) normal

• verweight obese

Fit 1.0 1.5 1.6 Not fit 3.1 4.5 5.0 Total death (RR) normal overweight obese Fit 1.0 1.1 1.1 Not fit 2.2 2.5 3.1 25,714 men, 44 years old, 14 year observational study

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Robert Baron, MD, MS

Sacks, NEJM, 2009

COMPARISON OF WEIGHT LOSS DIETS WITH DIFFERENT MACRONUTRIENTS

 RCT of 811 patients, 4 diets: fat/protein/carbs 20/15/65; 20/25/55; 40/15/45; 40/25/35  6 months: 6kg, 7% weight; at 2 years: completers lost 4kg; 15% lost 10% of weight  Results similar for:  15% pro v. 25% pro  20% fat v. 40% fat  35% carbs v. 65% carbs  Attendance highly correlated with weight loss; satiety, hunger, lipids, insulin all equal

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Robert Baron, MD, MS

Heterogeneity of Response to Weight Loss Diets: Insulin Resistance

• Insulin sensitive: low carb and high carb both

effective for weight loss

• Insulin resistant: low carb more effective

Very Low Calorie Diets (VLCD) vs Low Calorie Diets (LCD): Meta-analysis of 6 RCTs

• Trials with direct comparisons
• Short-term: mean 12.7 weeks
• Long-term: mean 1.9 years

Weight loss (as % of initial weight): short-term long-term LCDs 9.7 5.0 VLCDs 16.1 6.3 (p) (0.001) (0.2)

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Robert Baron, MD, MS

WEIGHT LOSS DIET BOTTOM LINE

• The type of diet does not really

matter for weight loss.

• Sticking to the diet does matter
• Calories “trump” macronutrients
• But, select healthy, nutrient rich

foods

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Robert Baron, MD, MS

40 yo woman, BMI 36. Much to your surprise (and satisfaction), she has lost 35 pounds. In order to maintain her new weight, her lifelong daily calorie intake should be:

• 1. 2000 kcals

2 1800 kcals 3 1600 kcals

• 4. 1400 kcals
• 5. 1200 kcals

SUCCESSFUL WEIGHT LOSS MAINTENANCE

• High levels of physical activity
• Women 2545 kcal/week, men 3293 kcal per week
• 1-hour moderate intensity per day
• Only 9% report no physical activity
• Diet low in calories
• 1381 kcal day
• 4.87 meals or snacks/day
• Fast food 0.74/week
• Regular self-monitoring of weight
• 44% weigh once per day; 31% once per week

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Robert Baron, MD, MS

40 yo woman, BMI 36. Much to your surprise, she has lost 35

• pounds. In order to maintain her

new weight, her lifelong daily calorie intake should be:

• 1. 2000 kcals

2 1800 kcals 3 1600 kcals

• 4. 1400 kcals
• 5. 1200 kcals

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Robert Baron, MD, MS

In the last year, I have prescribed a medication for weight loss.

• 1. Yes

2 No

The medication I have most commonly prescribed for weight loss is:

• 1. Phentermine
• 2. Orlistat (Xenical™, Alli™)
• 3. Locaserin (Belviq™)
• 4. Phentermine/topiramate (Qsymia™)
• 5. Buproprion/naltrexone (Contrave™)
• 4. Liraglutide (Saxenda™)
• 5. Other

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Robert Baron, MD, MS

The Neuroendocrinology of Energy Balance

Weight Loss With Weight Loss Medications

Weight loss (% of initial) in excess of placebo: Phentermine-fenfuramine 11.0% Sibutramine 5.0% Phentermine 8.1% Orlistat 3.4% Lorcaserin (2012) 3.0% Phentermine/topiramate (2012) 7.8-9.3% Buproprion/naltrexone (2014) 2-4% Liraglutide (2014) 3.7-4.5%

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Robert Baron, MD, MS

James, NEJM 2010

SIBUTRAMINE AND CARDIOVASCULAR OUTCOMES (SCOUT)

 9804 patients, over 55, with CV disease or diabetes  Sibutramine vs. placebo, 3.4 year f/u  Outcomes MI, stroke, cardiac arrest, CV death  Results

 Weight:

• 1.7 kg

 BP: 1.2 vs 1.4 mm Hg  Combined outcome: 11.4% vs. 10.0% (HR 1.16, p = 0.02)  Nonfatal MI: 4.1% vs. 3.1% (HR 1.28; p = 0.02)  Nonfatal Stroke: 2.6% vs 1.9% (HR 1.36; p = 0.03)  Death: No differences

Phentermine/Topiramate (Qsymia™) Side Effects

• Paraesthesia, dizziness, dysgeusia, insomnia,

constipation, dry mouth

• Fetal harm: cleft lip, cleft palate
• Mood disorders: anxiety and depression
• Suicidal thoughts or behavior
• Acute angle glaucoma
• Cognitive dysfunction: concentration memory,

language

• Metabolic acidosis and renal failure
• Hypoglycemia (in association with diabetes meds)
• Interactions with alcohol and sedatives

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Robert Baron, MD, MS

PRINCIPLES OF DRUG THERAPY

• NIH: BMI > 30 kg/m2 or 27 kg/m2 with co-

morbidity (but in my practice almost never)

• Motivated to begin structured exercise and

low calorie diet

• Begin medications at completion of one month

successful diet and exercise

• Continue medications only if additional weight

loss achieved in first month with meds

Wouldn’t It Be Easier Just To Have Surgery ?

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Robert Baron, MD, MS

Definition BMI Normal < 25 Overweight 25-29.9 Obese, class 1 30-34.9 Obese, class 2 35-39.9 Obese, class 3 40+ “Superobese” 60+

SURGERY with co-morbidity

INDICATIONS FOR BARIATRIC SURGERY

Types of Surgery

Restrictive

• Horizontal Gastroplasties
• Vertical Banded Gastroplasty (VGB)
• Silastic Ring Vertical Gastroplasty (SRVG)
• Adjustable Gastric Banding
• Sleeve Gastrectomy

Malabsorptive

• Jejunoileal Bypass (JIB)
• Biliopancreatic Diversion (BPD)
• Duodenal Switch
• Long Limb Gastric Bypass

Restrictive with Malabsorptive Component

• Roux-en-Y Gastric Bypass (RYGPB)

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Robert Baron, MD, MS

Surgical considerations

• Surgeon’s Experience
• Restrictive vs

Malabsorptive

• Open vs Closed

Sleeve Gastrectomy

Lap Band Gastric Bypass

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Robert Baron, MD, MS

Laparoscopic Adjustable Gastric Banding (LAGB)

Restrictive Only

Ideal Candidate – BMI 35-40 kg/m2 – Wants to lose 50-100 pounds Benefits – Fewer early risks than other procedures – One hour procedure – Fully Reversible/Removable – Lowest risk of vitamin deficiencies Considerations/Risks – Excess Weight Loss (EWL) 50% – 10-year removal or reoperation rate is >25% – Slower weight loss (1-2lbs/week) compared to other surgeries – Appetite suppression may be difficult to achieve – Least effective for resolving diabetes

LABS Consortium, NEJM, 2009

LONG-TERM OUTCOMES OF LAP BAND

• 151 patients, single center, 12 year f/u; 54.3% included

(82/151)

• Operative mortality: 0
• Mean weight loss: 20.75 kg (BMI from 41.6 to 33.8)
• 60% of patients satisfied; overall quality of life

unchanged

• 39% major complications; 60% required re-operation

Conclusion: Lap band results in poor long-term

• utcomes

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Robert Baron, MD, MS

Sleeve Gastrectomy (Vertical Gastrectomy)

Restriction and Resection

Ideal Candidate – BMI 35-55 kg/m2 – Wants to lose 80-150 lbs Benefits – Excess Weight Loss 70-90% – 1-2 hour procedure – Recovery ranges from days to weeks – Patients report early and lasting fullness – Intestines stay intact—No malabsorption – May cure diabetes Considerations/ Risks – Removal of a portion of the stomach is permanent – The remaining pouch may expand

• ver time

UCSF Sleeve Gastrectomy Indications

• Very high risk of co-morbidities
• BMI >60
• Possible non-compliance with meds

(less risk of micronutrient deficiencies)

• IBD, IBS, abdominal pain, SBO,

adhesions, other GI morbidities

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Robert Baron, MD, MS

Roux en Y Gastric Bypass (RNY or Bypass)

Restrictive and Malabsorptive

Most common procedure performed Ideal Candidate – BMI 35-55 kg/m2 – Wants to lose 100- 150 + lbs – May have severe or prolonged medical conditions Benefits – Excess Weight Loss 70-90% – 2 hour procedure – Recovery of days to weeks – Very effective for diabetes – Approximately 100-200 calories per day lost through malabsorption – Procedure is reversible Considerations/Risks – Greater risk for vitamin deficiencies – Dumping syndrome – Smoking, EtOH, NSAIDS use may lead to ulcers

Duodenal Switch

Restriction, Resection and Malabsortion

Ideal Candidate – BMI > 60 kg/m2 – Poorly controlled diabetic Benefits – Has the highest cure rate for diabetes – Excess Weight Loss 80-90%. – 3-4 hour procedure – 200-400 cal lost from malabsorption Considerations/Risks – Not offered by most surgeons – Stomach removal is permanent but bypass may be reversed – Highest risk for vitamin and protein deficiencies, diarrhea and intestinal blockages

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Robert Baron, MD, MS

Contraindications to Bariatric Surgery

• Severe cardiac disease with high risk for

anesthesia

• Severe coagulopathy
• Untreated major depression or

psychosis

• Binge-eating disorders
• Current drug or alcohol abuse
• Inability to comply with post op diet and

supplementations

Pre-op Evaluation

• Complete H and P
• “Routine” labs
• Nutrient screening ( Fe, Ferritin,TIBC, Vit D,

Folate, Mg, Phos

• Cardio-pulmonary (sleep, ECG, CXR, Echo)
• GI (H pylori, GB, EGD)
• Endo (A1C, TSH, androgens, Cushings
• Psych social evaluation
• Diet evaluation
• Health Care Maintenance

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Robert Baron, MD, MS Years

Bariatric Surgery: Weight Change

Resolution of Comorbidities

10 20 30 40 50 60 70 80 90 100

Diabetes Hyperlipidemia HTN Sleep apnea

Band VBG GBP D Switch

% Resolution Comorbidity

Bariatric Surgery – A Systematic Review and Meta-analysis Buchwald H. et al.

• JAMA. 2004; 292(14):1724-37

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Robert Baron, MD, MS

ADA Practice Guidelines Bariatric Surgery for Diabetes

 Bariatric Surgery may be considered for

adults with BMI > 35 and type 2 DM, especially if diabetes and comorbidities are difficult to control with lifestyle and meds

 Although small trials have shown

glycemic benefit with BMI 30-35 and DM, there is currently insufficient evidence to recommend surgery

ADA, Diabetes Care 2015 LABS Consortium, NEJM, 2009

BARIATRIC SURGERY ADVERSE OUTCOMES

• Ten sites, 4776 patients. 3/4 roux-en-y (87% lap); 1/4 lap band
• 30 Day overall mortality: 0.3%
• lap band

0.0%

• roux-en-y (lap)

0.2%

• roux-en-y (open)

2.1%

• Composite (death, DVT, reintervention, 30 + days in hosp): 4.1%
• lap band

1.0%

• roux-en-y (lap)

4.8%

• roux-en-y (open)

7.8%

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Robert Baron, MD, MS

Mortality After Surgery

Community Medicare Data: 55-64 year old

30 days 90 days 1 Year 2.0% 2.7% 5.2% Post-operative Complications

Gastric Banding

• Band

Slippage

• Band Erosion
• Port infection
• Injury to

adjacent

• rgans
• Death within

30 days (<0.5% of patients) Sleeve Gastrectomy

• Leakage
• Bleeding
• Abdominal pain
• Poor wound

healing

• Narrowing/Steno

sis

• Reflux
• Death within 30

days (<1% of patients) Bypass Surgery

• Leakage
• Bleeding
• Stoma
• bstruction
• Small bowel
• bstruction
• DVT
• Protein-calorie

malnutrition

• Death within 30

days (<1% of patients)

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Robert Baron, MD, MS

Additional Post-Operative Complications

• Mood Changes
• Excessive Vomiting
• Gas
• Dumping Syndrome
• Hair loss
• Eustachian Tube Dysfunction

Sjostrom, NEJM, 2007

Bariatric Surgery and Mortality

Swedish Obese Subjects Study

• 4047 subjects, surgery vs. matched control. 10.9 years

Max weight loss % Final weight loss % Control 2 Gastric bypass 32 25 Vertical banded Gastroplasty 25 16 Banding 20 14

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Robert Baron, MD, MS

Sjostrom, NEJM, 2007

Bariatric Surgery and Mortality

Swedish Obese Subjects Study

Deaths HR Rate MI deaths Cancer deaths Control 129 0.063 25 47 Surgery 101 0.76 0.050 13 29 (p = 0.04)

NNT 77 over 11 years (approx 850 per year)

Diet and Exercise After Surgery

Days 1-14

• Thin fluids only
• No solid food
• 32-60 oz fluids per

day

• 400-600 calories

per day

• 50-70 grams of

protein

• Walk 5-10 minutes

every hour

• Wake and walk

after 8 hours

Days 15-30

• Start thick liquids

and soft foods

• 32-60 oz fluids
• 600 calories per day
• 50-70 grams of

protein

• Minimal carbs and

fats

• Start cardio

exercises and light weight lifting

Day 31 and beyond

• Regular foods as

tolerated

• Meats and other

foods should be tender, cut and chewed well and eaten slowly

• 60+ oz fluids
• 600 calories per day
• 50-70 grams of

protein

• Increase physical

activity

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Robert Baron, MD, MS

Keys to Success

DO THIS

• Protein first, Goal 60+ g/day
• Eat 3 meals per day, Goal 600

cal/day

• Chew Chew Chew
• Drink water between meals
• Drink 64 oz fluids per day
• Measure and track all intake
• Exercise 30 to 60 minutes daily
• Weigh weekly
• Take your vitamins

DON’T DO THIS

• Eat sweets or excessive

carbohydrates

• Overeat or graze
• Drink within 30 minutes of

eating

• Drink carbonated beverages
• Drink through a straw
• Drink caffeine and alcohol
• Eat soft or high calorie foods
• Exceed calorie limits per day

Recommended Follow-Up Labs

Basic labs

• CBC
• Electrolytes
• BUN and

creatinine

• Liver panel
• Lipid panel
• Glucose and

A1C

Deficiencies

• Folate
• Iron,

ferritin, and TIBC

• B-12
• Calcium
• Vitamin D

Also consider

• Magnesium
• Phosphorus
• B6
• Thiamine (B1)
• Zinc
• Copper
• Vitamin A

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Robert Baron, MD, MS

Medication Issues After Surgery

• Diuretics are discontinued in the hospital
• Attempt to use immediate-release, crushed, liquid
• r chewable preparations
• Patient are often discharged from the hospital off

HTN and DM meds

• If meds are needed in diabetics use immediate

release Metformin and/or sliding scale insulin

• Avoid delayed, enteric-coated and extended-release

preparations after malabsorption procedures

• Some meds require gastric acidity for dissolution
• Avoid NSAIDS, EtOH and smoking cessation to

prevent ulcers

Pregnancy and Weight-Loss Surgery

• Fertility is enhanced

after surgery

• Delay pregnancy for

12 to 18 months after surgery

• Use non-oral forms
• f birth control
• Avoid oral glucose

challenge after gastric bypass

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Robert Baron, MD, MS

Managing Excess Skin

SUMMARY

 Environmental and public health changes work.  Diets work, but not for long in most people (but

they do for some).

 Exercise improves health independent of

weight change and aid in weight maintenance.

 Continuation of conditions that promote weight

loss promotes weight maintenance (no matter what the intervention).

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Robert Baron, MD, MS

SUMMARY

 Provision of meals and meal replacement

products promote greater weight loss (but mostly in the short term, except for a few).

 Medications can help achieve small

amounts weight loss for as long as agents can be used (but little is known about long term outcomes).

 Surgery results in long term weight loss

and reductions of diabetes and mortality (but with complications in some/many and a high number needed to treat).

GOALS OF MANAGEMENT

 Be as fit as possible at current weight  Prevent further weight gain  If successful at 1 and 2, begin weight

loss

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Robert Baron, MD, MS

The Magic Formula