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Pharmacologic and Surgical Management of OBESITY in Primary Care. Rey Vivo, MD Assistant Professor of Medicine Texas Tech University Health Sciences Center. Which of the following is/are true regarding obesity? A. Obesity is generally defined as BMI > 30

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pharmacologic and surgical management of obesity in primary care

Pharmacologic and Surgical Managementof 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

What is the best answer?
objectives
Define overweight and obesity

Epidemiology trends

Contributing factors

Health consequences

ACP Management Guidelines

Pharmacologic

Surgical

Objectives
definitions
Definitions
  • Body Mass Index (BMI)
    • Formula: weight (kg) / [height (m)]2
    • Formula: weight (lb) / [height (in)]2 x 703
  • Caveats:
    • Women
    • Elderly
    • Highly-trained athletes
    • Abdominal fat
what is the best answer1
In 2006, the following states had the lowest prevalence of obesity (< 20%) except:

A. Connecticut

B. Massachusetts

C. West Virginia

D. Hawaii

E. Colorado

What is the best answer?
epidemiology obesity trend 1990
Epidemiology:Obesity Trend 1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: Centers for Disease Control and Prevention

epidemiology obesity trend 1998
Epidemiology:Obesity Trend 1998

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: Centers for Disease Control and Prevention

epidemiology obesity trend 2006
Epidemiology:Obesity Trend 2006

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: Centers for Disease Control and Prevention

what is the best answer2
The following medical conditions may cause obesityexcept:

A. Cushing’s syndrome

B. Hypothyroidism

C. PCOS

D. Growth hormone excess

What is the best answer?
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)

Contributing Factors
classic abim question
In the IM Boards, obesity if a risk factor for which 2 medical conditions?

A. Osteoarthritis and Uterine CA

B. Osteoarthritis and Osteoporosis

C. Uterine CA and Osteoporosis

D. Uterine Ca and Sleep Apnea

“Classic” ABIM Question
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)

Health Consequences
recommendation 1
ALL obese patients should be counseled on therapeutic lifestyle changes such as:

Diet

Exercise

Individualized weight and health goals

Recommendation # 1
slide15

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 # 2
recommendation 3
Adjunctive drug therapy options include:

Sibutramine

Orlistat

Phentermine

Diethylpropion

Fluoxetine

Bupropion

Choice will depend of side effects and patient’s tolerance

Recommendation # 3
slide19

Myocardial Infarction Induced by

Appetite Suppressants in MalaysiaThe 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.Recommendation # 4
types of bariatric surgery
Types of Bariatric Surgery

Vertical banded gastroplasty

Biliopancreatic diversion

Figures from utdol.com

roux en y gastric bypass
Roux-en-Y gastric bypass

Figures from utdol.com

bariatric surgery complications top 10
Bariatric Surgery Complications:Top 10

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

Nutritional Complications

Malinowski SS. Am J Med Sci. 2006;331:219-225.

nutritional complications1
Micronutrient

Vitamin B12

Iron

Folate

Calcium

Thiamine

Fat-soluble vitamins

Nutritional Complications
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

Another Complication
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

Take Home Points

MANAGEMENT MUST BE INDIVIDUALIZED

AND THOROUGHLY DISCUSSED

WITH A MULTI-DISCIPLINARY TEAM.

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