Update on Bariatrics Nothing to Disclose Jonathan Carter, MD - PowerPoint PPT Presentation

Update on Bariatrics Nothing to Disclose Jonathan Carter, MD Jonathan Carter, MD Associate Professor of Surgery Associate Professor of Surgery 6/20/2018 6/20/2018 Case Presentation: Patty 33 year-old woman with morbid obesity. 5’5” 262 lbs BMI 44 Morbidly obese since childhood. She has tried Weight Watchers, Curves, South Beach Diet, Low Carb Diet, Atkins Diet, Slim-Fast, Nutrisystem and the UCSF Medically Managed Weight Loss Program. Although she has been able to lose some weight from diets and exercise, over time the weight has always returned, Patty and she has remained morbidly obese 262 lbs Past Medical History Hypertension Migraine Diabetes mellitus (HBA1C 6.7%) Asthma Intertrigo Urinary stress incontinence Polycystic ovarian syndrome 1

What can we offer Patty? What can we offer Patty? 1. There are more and more patients like Patty and the 1. There are more and more patients like Patty and the obesity epidemic continues without a plateau in sight. obesity epidemic continues without a plateau in sight. 2. We have new insights about why diets fail in the long 2. We have new insights about why diets fail in the long run. run. 3. No effective and durable drug therapy for severe 3. No effective and durable drug therapy for severe obesity exists. obesity exists. 4. Bariatric surgery has evolved rapidly 4. Bariatric surgery has evolved rapidly • Band out, Sleeve in, Bypass still the gold standard • Band out, Sleeve in, Bypass still the gold standard • Safety now better than cholecystectomy, • Safety now better than cholecystectomy, hysterectomy. hysterectomy. • Durability of weight loss now firmly established. • Durability of weight loss now firmly established. • Metabolic surgery is now the focus. • Metabolic surgery is now the focus. 1990 1995 https://stateofobesity.org/adult-obesity/ 2

2000 2003 2004 2005 3

2006 2007 2008 2009 4

2010 2011 2012 2013 5

2014 2015 Why is obesity unhealthy? 2016 RESPIRATORY CARDIOVASCULAR obstructive sleep apnea Hypertension Pickwickian syndrome Congestive Heart Failure asthma Cor pulmonale GASTROINTESTINAL Varicose veins GERD Pulmonary embolism Fatty liver disease / NASH Coronary artery disease Hernia ENDOCRIN E Colon cancer Metabolic syndrome GENITOURINARY Type 2 diabetes Urinary stress incontinence Dyslipidemia Obesity-related glomerulonephropathy Polycystic ovary syndrome Hypogonadism Amenorrhea, infertility, menstrual disorders Breast and uterine cancer MUSCULOSKELETAL Pregnancy complications Gout NEUROLOGIC Osteoarthritis Stroke Lower back pain Idiopathic intracranial hypertension Carpal tunnel syndrome Meralgia paresthetica SKIN Dementia dermatoliposclerosis PSYCHOLOGIC lymphedema Depression cellulitis Low self-esteem intertrigo Body image disturbance hidradenitis suppurativa Social stigmatization Mechanick et al. SOARD 2008 6

Obesity reduces life expectancy What can we offer Patty? Years of lost life expectancy in women 1. There are more and more patients like Patty and the 10 obesity epidemic continues without a plateau in sight. 8 2. We have new insights about why diets fail in the long run. 6 4 3. No effective and durable drug therapy for severe obesity exists. 4. Bariatric surgery has evolved rapidly 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 • Band out, Sleeve in, Bypass still the gold standard • Safety now better than cholecystectomy, BODY MASS INDEX hysterectomy. • Durability of weight loss now firmly established. • Metabolic surgery is now the focus. Randomly assigned 811 patients to 4 groups: low fat, low protein high fat, high protein low fat, high protein high fat, low protein Intensive group/individual instructional sessions Intensive follow-up to 2 years 7

“They [study patients] were offered 59 group and 13 individual training sessions over the course of two years… [But] even these highly motivated, intelligent participants, who were coached by expert professionals, could not achieve the weight losses needed to reverse the obesity epidemic.” - Katan, NEJM 2009 14 participants of “The Biggest Loser” competition Participants were studied 1. prior to participation in the show 2. at the end of the 30 week competition 3. 6 years later 30 weeks: VLCD exercise 8

Outcome variables Methodology Measured resting metabolic • Indirect calorimetry rate (RMR) • Fast for 12 hours, then lay supine • Breath into metabolic cart for 15 min • Measure O2 intake and CO2 emission • Calculate Resting Metabolic Rate (RMR) Body composition • By dual-energy x-ray absorptiometry • Measures Fat Mass (FM) and Fat-Free Mass (FFM) Predicted RMR Indirect calorimetry to measure resting metabolic rate Fast for 12 hours Breathe into Total energy expenditure • Clearance of 18 O H 2 O and 2 H H 2 O over 2 weeks • CO2 generation calculated, used to calculate TEE Metabolic Adaptation = RMR (measured) – RMR (predicted) = the difference between what you are actually burning versus what you should be burning based upon your body composition, age, and sex. Reflects the body’s ability to slow metabolic rate in order to preserve fat mass In lay terms, is the body’s “starvation mode” 9

What happened at 6 years? Body weight change Fat-free mass change Fat mass change in kilograms in kilograms in kilograms What happened at 6 years? Metabolic adaptation foils long-term attempts at dieting Obesity is not a disease of gluttons and sloths. The body acts to preserve the fat mass set point. Diet and exercise do not change the set point. 10

The Good... Phentermine About 5% loss in total body weight What can we offer Patty? beyond placebo FDA approved (schedule IV controlled) 1. There are more and more patients like Patty and the The Bad... obesity epidemic continues without a plateau in sight. Side effects: dry mouth 2. We have new insights about why diets fail in the long insomnia run. dizzyness hypertension Mechanism: 3. No effective and durable drug therapy for obesity tachycardia exists. abuse potential stimulant similar to amphetamine About 50% drop out of therapy from 4. Bariatric surgery has evolved rapidly side effects. • Band out, Sleeve in, Bypass still the gold standard • Safety now better than chole or Only indicated for SHORT TERM use • The weight stays off for most – rigorous durability The Ugly... • Metabolic surgery more and more accepted Phen-Fen still fresh in everyone’s mind (induced severe pulmonary HTN and/or cardiac valve disease) The Good... The Good... Orlistat (Xenical) Rimonabant Over one year, good for about 4-8 About 5% weight loss beyond placebo pounds over placebo May also help with smoking cessation FDA approved for LONG term use The Bad... Reduces DM, HTN The Bad... Side effects: nausea Side effects: depression Mechanism: Mechanism: oily spotting diarrhea staining with flatus pancreatic lipase inhibitor in the GI tract antagonist of cannibinoid receptor CB1 fecal urgency NOT FDA approved steatorrhea The Ugly... Decreases LDL cholesterol Europe approved, then later withdrew Requires daily vitamin ADEK dosing because of suicides (2x risk of psychiatric disorder and 10% The Ugly... depression, 1% suicidal ideation 3x risk of acute kidney injury FDA label: risk of severe liver injury 11

The Good... The Good... Qsymia Lorcaserin (Belviq) About 10% weight loss beyond placebo About 4-8 pounds additional weight loss at 12 weeks beyond placebo FDA approved in 2012 FDA approved in 2012 – Schedule IV Lowers BP. Benefit in sleep apnea. Not a lot of side effects! The Bad... The Bad... Side effects: Side effects: dry mouth Mechanism: Mechanism: hallucinations tingling fingers phentermine: stimulant selective serotonergic agonist 5HT2c constipation topiramate: anticonvulsant Initially declined by FDA over concerns BIRTH DEFECTS about safety. FDA reversed decision in 2012. DEA lists as Schedule IV Initially declined by FDA over concerns narcotic. about suicidal thoughts, palpitations, memory lapses, and cleft lip/palatte The Ugly... The Ugly... Heart valve damage? Need to wait for post marketing studies.... Requires monthly urine pregnancy tests! Patty We performed an intervention…… 262 lbs 12

Patty 2 months after 252 lbs 208 lbs Day of intervention 6 months 4 months after 180 lbs 13

6 months after 8 months after 161 lbs 149 lbs 10 months after 12 months after 146 lbs 143 lbs 14

18 months after 2 years after 142 lbs 138 lbs …first half-marathon! 2 year check-up: Weight: 138 pounds BMI 21.6 What was the intervention? Hypertension: resolved. Off all meds. Diabetes: complete resolution. HBA1C 5.6% PCOS: just stopped OCPs, trying to get pregnant Migraines: none in last year Asthma: resolved Stress incontinence: resolved 15