Adult Obesity Medicine In A Nutshell - PeaceHealth

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AdultObesity Medicinein a NutshellKENNA WOOD, DODiplomate American BoardOf Obesity Medicinekwood3@peacehealth.org

Disclosures I have no financial disclosures

Purpose of this presentation Provide a broad overview of thepractice of obesity medicineDetails on the slides can be usedas a guide

ObjectivesUnderstand why obesity isconsidered a disease withmultiple etiologiesUnderstand how to communicatewith patients about their weightand secondary conditionsUnderstand the fundamentals ofdiscussing physical activity andvarious diet options to treatobesityUnderstand the importance ofsleep in affecting weightUnderstand the medications thataffect weightReview the laws affectingcontrolled medications forbariatric practiceReview sources of additionalcontinuing medical education onobesity medicine

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

Definitions OverweightBMI 25.0-29.9 Class 1 obesityBMI 30.0-34.9 Class 2 obesityBMI 35.0-39.9 Class 3 obesityBMI 40.0

https://www.cdc.gov/obesity/data/databases.html

https://www.cdc.gov

Weight bias Check your biases at the door No one deserves weight problems Every patient deserves respect

What factors contribute toobesity? Food environment StressMicrobiome Home Society Hormones Genetics Sleep Sedentarylifestyles/sedentary jobsDisability

Foodenvironments

Food environment (or lack of access to healthy foods)

HormonesWait, what?!!!

Sicat, J. Pathophysiology (Part 1) OMA presentation

Genetics

Genetics PraderWilli Leptin deficiency

Genetics MC4R Anddeficiencymany others

Sleep

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 atend of study

Evidence Wisconsin Sleep Study, Taheri et al. Sleep 2004. N 1024. Adults With with 7.7 hrs sleep had the lowest BMIless sleep, lower leptin levels, & higher ghrelin levelsReproduced 2 additional studies (n 12 and n 740)

Stress

IntestinalMicrobiomes:associated withobesity

Sedentary jobs/lives

Disability

“Eat less, move more”is not how it worksIt is not that simple.

How do you get started? Ask permission to discuss weightDiscuss: Diet Exercise Sleep/screen for sleep apnea Review medications Determine if medications that control hungerare appropriate to start Determine if patient is a candidate forbariatric surgery

Definition of success 5-10 % total body weight loss within 6months and maintained for at least 1 year

Diet Start with simple changes: Cut down/eliminate sugar sweetenedbeverages & ALL soda Increase vegetable intake Consider meal replacements as an option Use small plates Food order matters

Diet Food order matters Shukla et al. 2015 N 11 Lower glucose &insulin levels withprotein & veggiebefore simplecarbsShukla et al. 2015

Diet Primary diets used for weight loss Plant based dietLow carbohydrate diets (high protein or highhealthy fat/moderate protein) How many grams of carbs? What about patients with CKD, gout, renal stones, gallstones?Mediterranean diet

Mediterranean diet VS Low FatDiet PREDIMED- Primary Prevention of CVD with a Mediterranean Diet Supplemented with EVOOor 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 thanlow fat diet, relative difference of 30%NEJM 2018 PREDIMED

A to Z Weight Loss Study Comparison of the Atkins, Zone, Ornish, and LearnDiets, 2007, N 311, 1 year trial Weight loss significantly better in Atkins dietcompared to Zone dietNo significant statistical difference between weightloss 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

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 Lowcarbohydrate & Mediterranean diets may beeffective alternatives to low fat diets Mediterranean diet: more favorable effects onglycemic controlLow carb diet: more favorable effects on lipidsShai et al. 2008

Fasting Intermittent fasting Daily fasting Alternate day fasting Eating only within an 8 hour window eachdayWhat can you eat/drink during fasting?Must adjust insulin and oral anti-hyperglycemicmedications for fasting

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

Sleep Insomnia Primary or secondary causes Referral, if appropriateObstructive or central sleep apnea Screen If already diagnosed: Are they using appropriate therapy? Is their equipment working well?

Medications that can causeweight 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 mayalso have affects Mood stabilizers: gabapentin, lithium, valproate,vigabatrin, carbamazepine Migraine medications: amitriptyline, gabapentin,paroxetine, valproic acid, someBB Antipsychotics: clozapine, olanzapine, zotepine(substantial), quetiapine,risperidone, lithium Possible but less likely:aripiprazole, haloperidol,lurasidone, ziprasidone Hypnotics: diphenhydramine

Medications that can causeweight loss: Diabetes: metformin, GLP-1agonists, SGLT-2inhibitors, alphaglucosidaseinhibitorsHormones:testosterone might Anti-seizure: upropionMood stabilizers:lamotrigineMigraine: topiramate

Medications that are used forweight loss: MetforminPhentermine, phendimetrazine, ate)Belviq (lorcaserin)Naltrexone/bupropion (Contrave)Saxenda (GLP-1 agonist)Orlistat

Is bariatric surgeryappropriate? NationalInstitutes of Health (NIH) established criteria forbariatric surgery in 1992 and are still the most widelyused: BMI 30 with obesity related comorbidity (gastricband only) BMI 35-39.9 with a high risk comorbidity BMI tes

Is bariatric surgeryappropriate? ASMBSupdated position statement on bariatric surgeryin class 1 obesity- Aug 2018 For patients with BMI 30 to 35 kg/m2 and obesity-related comorbiditieswho do not achieve substantial, durable weight loss and co-morbidityimprovement with reasonable nonsurgical methods, bariatric surgeryshould be offered as an option for suitable individuals. In this population,surgical intervention should be considered after failure of nonsurgicaltreatments. Particularly given the presence of high-quality data inpatients with type 2 diabetes, bariatric and metabolic surgery should bestrongly considered for patients with BMI 30 to 35 kg/m2 and type -candidates

How long do you treatoverweight/obesity?How long would you treat any other chronicdiagnosis once it is finally under control? Forever, if needed since it will be a long-term problem Obesity is a chronic disease

Medications: who is a candidateto treat with medications? Not everyone BMI 27.1-29.9 with acomorbidity BMI 30.0 with/without acomorbidity

Laws for writing controlled weightloss medications More limited prescribing than opioids i.e. more rules Oregon Medical Board, Chapter 847, Division 15GENERAL LICENSING RULES, RELATING TO CONTROLLED SUBSTANCES 847-015-0010 Schedule III or IV Controlled Substances — Bariatrics PracticeStatutory/Other Authority: ORS 677.265Laws are different by state. Know your state’slaws!

Rules posted on OMB website: Must prescribe in accordance with FDA productguidelines in effectMust co-prescribe caloric reduction, behaviormodification, and exercise, provided that all ofthe following conditions are met: Thoroughly review prior treatments (yours andothers) to determine if the following conditionsexist: BMI 30 or BMI 27 & weight threatens health (comorbidity)

Rules posted on OMB website: Licensee obtains thorough history, thoroughphysical exam, rules out contraindications touse of controlled substance. (Get an EKG!)To continue Rx beyond 3 months requiresdocumentation Average 2 lb/mo weight loss during active weightreduction treatmentGoal weight maintenance once maintaining weightonly

Copied from OMB Webpage: Violations of this rule constitute“Unprofessional Conduct as the term isused in ORS 677.188(4)(a), (b), or (c),whether or not actual injury to a patient isestablished.”

Helpful hints to avoid insuranceproblems Don’t link any off-label medications to the diagnosis ofobesity/overweight unless you want to see the Rxdenied by insurance Don’t list “overweight” or “obesity” as the primarydiagnosis Primary code should be an associated and/orsecondary diagnosis (i.e. PCOS, OSA) Medicare does cover obesity as a primary diagnosisbut requires very specific documentation

Obesity CME Obesity Medicine Association (OMA) The Obesity Society (TOS) Harvard Medical School Columbia University The Endocrine Society Local CME programs: Legacy/OHSU

American Board of ObesityMedicine (ABOM) Certification Fellowship pathway Completion of on-site 500 hours of obesity orobesity-related conditions CME pathway Minimum 60 credits CME on topics of obesity (AOAcat 1-A, AMA PRA cat 1) 30 must be earned through attendance atspecific sites; other 30 can be earned inattendance or online CME This pathway may end in the next few years

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, NY20 new programs to open in 2020

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

Do you have to seek ABOMcertification? No, you can simply assist patients in yourpractice

EDUCATIONAL RESOURCES FORHEALTH CARE PROFESSIONALS Use these resources to furtheryour education – and yourstaff’s and patients’ education –about clinical obesitytreatment.Patient Resources Obesity Action Coalition (OAC) www.obesityaction.orgPhysician 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 ClinicalEndocrinologists www.aace.org

EDUCATIONAL RESOURCES FORHEALTH CARE PROFESSIONALS American Cancer Society www.cancer.org American College of SportsMedicine www.acsm.org American Diabetes Association www.diabetes.org American Heart Association www.heart.org American Society forMetabolic & Bariatric Surgery www.asmbs.org Canadian Obesity Network www.obesitynetwork.ca Hormone Health Network www.hormone.org Mental Health America www.mentalhealthamerica.org

EDUCATIONAL RESOURCES FORHEALTH CARE PROFESSIONALS National Association of AnorexiaNervosa and Associated Disorders www.anad.org National Cancer Institute www.cancer.gov National Eating Disorders Association www.nationaleatingdisorders.org National Institute of Diabetes andDigestive and Kidney Diseases www.niddk.nih.gov National Heart, Lung, and BloodInstitute 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

References Centers for Disease Control (2015), Obesity trends among USAdults. Retrieved l Estruch, R., Ross, E., & Salas-Salvado, J. (2018). Primaryprevention of cardiovascular disease with a Mediterranean dietsupplemented with extra-virgin olive oil or nuts. New EnglandJournal 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.

References Hasler, G. et al. (2004). The association between short sleepduration and obesity in young adults: a 13 year prospective study.Sleep. 27(4), 661-6. Lenard NR (2008). Central and peripheral regulation of foodintake 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 ofMedicine, 359(3), 229-241.

References Sicat, J. (2017). Pathophysiology (Part 1) Presentation forObesity Medicine Association. Image slide 29. Shukla, A. et al. (2015). Food Order Has a Significant Impact onPostprandial Glucose and Insulin Levels. Diabetes Care, 38, e9899. Taheri, S. et al. (2004). Short sleep duration is associated withreduced leptin, elevated ghrelin, and increased body mass index.PLoS Medicine, 1(3), e62.

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

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