WEIGHT LOSS SURGERY Pre-Clinic Conference Jennifer Kinley, MD 12/15/2010
EDUCATIONAL OBJECTIVES: Discuss the available pharmaceutical options for weight loss and risks of these medications Explain the indications, risks and benefits of bariatric surgery Describe the different types of bariatric procedures Become familiar with clinic resources to aid in weight loss Increase awareness of decision aids and improve shared decision making
FIRST VISIT: Your patient is a 39 year old African American female with morbid obesity ( BMI 49) who presents to clinic with concerns regarding weight loss. Her other comorbidities include diabetes, hypertension, hyperlipidemia and sleep apnea. She suffers from depression which she relates to her weight. You have seen her several times in clinic over the last two years while she has attempted to lose weight. She has tried multiple diets but cannot seem to keep the weight off. She tries to be walk daily but reports increasing pain in her hips and knees with activity.
She inquires about medications to help her lose weight. Name some medications that are available and their risks. Weight loss medications have been shown to be effective when combined with diet and behavioral modifications. However, these agents have only been approved for short term use and patients often regain weight when these medications are discontinued.
PHARMECUETICAL WEIGHT LOSS Phentermine or diethylpropion are adrenergic stimulants. Weight reduction of 3-4% Risks: palpitations, htn, primary pulmonary hypertension and/or cardiac valvular disease, potential for dependency. Sibutramine is an SNRI. Withdrawn from the market. The Cardiovascular OUTcomes (SCOUT) trial, showed an increased risk of heart attack and stroke in sibutramine-treated patients with cardiovascular disease. Orlistat is a lipase inhibitor. Side effects include flatus and fecal urgency. 13 total reports of severe liver injury associated with orlistat. Topiramate is an anticonvulsant. Side effect of weight loss. Average 6.5 kg more than those on placebo.
You both decide that medications are not ideal for long term weight loss. She would like to focus on diet modification. Are there any clinic resources you could offer her?
EAT LESS, MOVE MORE Life style approaches to weight loss should be first line treatment for obesity. Reduced calorie diets, such as eating 500kcal per day can result in weight loss of one pound per week. Very low fat diets < 15% calories from fat can lead to weight loss of 24 pounds a year but adherence is difficult. Randomized trials comparing commercial weight loss programs like Weight Watchers, Atkins, Ornish and Zone diets: Modest statistically significant weight loss at 1 year, no differences between diets 25% of the initial participants sustained a 1-year weight loss of more than 5% of initial body weight 10% of participants lost more than 10% of body weight. Adherence did decrease as the study progressed
NUTRITION RESOURCES Nutrition counseling is available depending on patient insurance. Circle this at the bottom of the check out sheet. Victoria Hawk, clinical nutritionist, will schedule an initial assessment with the patient which typically lasts 30-60 minutes. If patients would like to continue nutrition counseling, insurance may cover up to six visits. Nutrition handouts are available in the clinic
SECOND VISIT She returns to the clinic six months later. She has had six meetings with the nutritionist and is restricting her calories. However, she has only lost fifteen pounds. She asks you about weight loss surgery and if you would recommend this for her. She is very concerned about her health. Multiple family members have diabetes and her father had a heart attack at age 44.
What types of bariatric surgical procedures are available?
TYPES OF BARIATRIC SURGERY Bariatric surgery alters GI tract anatomy. Restrictive versus malabsorptive Adjustable gastric banding: insertion of a subcutaneous reservoir, gastric restriction is adjusted with saline injections. Sleeve gastrectomy: reduction of much of the gastric body leaving a narrow tube. Roux-en-Y bypass: stomach is stapled to create a small pouch. The intestines are divided at midjejunum, with distal portion connected to gastric pouch. The distal stomach and proximal small intestines are anastomosed further down the jejunum. Biliopancreatic diversion: part of the stomach is resected, creating a smaller stomach, distal part of the small intestine is then connected to the pouch, bypassing the duodenum and jejunum.
TYPES OF WEIGHT LOSS SURGERY
What are the indications for bariatric surgery? Are there any contraindications? Would your patient be appropriate for referral?
INDICATIONS/ CONTRAINDICATIONS Indications: BMI of 40 or higher, or BMI of 35 with serious obesityrelated comorbidities (diabetes, obstructive sleep apnea, coronary artery disease, debilitating arthritis) Previous failed weight loss attempts involving an integrated nonsurgical weight loss program including dietary modification, behavioral support, and appropriate exercise Appropriate motivation and psychological stability Contraindications: Mental or cognitive impairment, unstable CAD, advanced liver disease, BMI > 70 due to increased operative complications, weight gain from secondary causes such as hypothyroidism or Cushings, medication induced weight gain (antidepressants, contraceptives or hypoglycemics). Yes, your patient would be appropriate based on her BMI, comorbidities and failed attempts at weight loss.
What are the benefits of bariatric surgery for morbid obesity?
BENEFITS OF WEIGHT LOSS SURGERY Buchward et al.study: 77% of patients with diabetes no longer needed medication, 83% had improved hyperlipidemia, 66% had improvement of hypertension and 83% had improvement of their sleep apnea. The Swedish Obese Subjects: 2010 patients had bariatric surgery and 2037 patients had conventional treatment. At 2 yrs:23.4% body weight lost vs 0.1% gained At 10 yrs:16.1% body weight lost vs 1.6% gained Overall mortality was reduced by 31.6% in the surgery group versus the control group.
What are the risks of bariatric surgery?
RISKS OF WEIGHT LOSS SURGERY Operative mortality is 0.5% for gastric bypass and 0.1% for gastric banding. Perioperative: Pulmonary embolism Anastomotic leaks Infections Bleeding Incidental splenectomy Hernias Small bowel obstruction. Post operative: Nausea and vomiting Dumping syndrome Deficiencies: iron, calcium, folate, B12 and vitamins ADEK
You want to practice shared decision making and would like her to be fully informed about what this procedure entails however your time is limited. Are there any clinic resources that you could give her to provide further information?
DECISION AIDS Patients had greater knowledge Lower decisional conflict related to feeling uninformed Lower decisional conflict related to feeling unclear about personal values Reduced the proportion of people who were passive in decision making Reduced proportion of people who remained undecided post-intervention
PRESCRIBING DECISION AIDS o Go to Clinic Support Website o Under Patient Centered Medical Care o Click Patient Decision Aid Prescription Form
PRESCRIBING DECISION AIDS o Enter provider and patient name o Choose if you would like mailed or delivered to patient room o Make sure to choose which decision aid
THIRD VISIT She returns to your clinic six months after receiving gastric bypass surgery. She has lost 30% of her body weight. Her mood has dramatically improved. She is no longer requiring medication for her diabetes. Her hypertension and hyperlipidemia have resolved. She is much more active and reports less joint pain.
REFERENCES Eckel, R. Nonsurgical Management of Obesity in Adults. N Engl J Med, 2008; 358: 1941-50. DeMaria, E. Bariatric Surgery for Morbid Obesity. N Engl J Med. May 2007; 356: 2176-83. Sjostrom,L. Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects. N Engl J Med. Aug 2007; 357: 741-52. Huizinga, M. Weight-Loss Pharmacotherapy: A Brief Review. Clinical Diabetes October 2007 vol. 25 no. 4 135-140 Dansinger, ML. et al. Comparison of the Atkins, Ornish, Weight Watchers, and Zone Diets for weight loss and heart disease risk reduction: a randomized trial. JAMA 2005; 293; 43-53. O'Connor A. Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews 2009; 3. CD001431