Drugs and Surgery for Weight Loss Flashcards
What is the primary focus of bariatric surgery?
Support weight loss and treat or prevent obesity-related comorbidities
Examples of comorbidities include diabetes, hypertension, and obstructive sleep apnea.
What are the eligibility criteria for bariatric surgery?
BMI > 40 kg/m2 or BMI between 35-40 kg/m2 with major comorbidities (typically 1 in 171 individuals).
Major comorbidities include severe sleep apnea and severe diabetes.
What are the contraindications for surgery eligibility?
> 60 years of age, medical conditions that may make the surgery “high risk,” pregnancy, genetic conditions, mental health disorders, substance/ alcohol abuse, unwillingness to make lifestyle changes.
What are the types of bariatric surgical procedures?
- Restrictive
- Malabsorptive
- Mixed procedures
What is the role of the Edmonton Adult Bariatric Specialty Clinic?
Provides medical, psychological, and surgical interventions for weight management
Includes individualized care plans and assessments for bariatric surgery.
What is the difference between restrictive and malabsorptive procedures?
Restrictive procedures restrict the amount of food that the stomach can hold, but does not interfere with normal digestion.
Malabsorptive procedures combine stomach restriction with a partial bypass of the small intestine, reducing the amount of calories/ nutrients that the body absorbs.
What is adjustable gastric banding (AGB)? What are the disadvantages?
A restrictive surgery in which an adjustable gastric band is placed around the top portion of the stomach to treat obesity, intended to decrease food consumption.
> 5% failure rate due to balloon leakage, band erosion and deep infection. Also has a slower initial weight loss and less improvement of diabetes.
What are the advantages of Adjustable Gastric Banding (AGB)?
- Simple and relatively safe
- Very short recovery period
- Major complication rate is low
- No altering of the natural anatomy
What is sleeve gastrectomy? What are the advantages?
A restrictive procedure that involves removing about 80% of the stomach, leaving a tube-shaped stomach about the size and shape of a banana.
Reduces food intake (removes Ghrelin Cell mass: lower hunger)
No malabsorption of nutrient
Low potential for leakage
What are the disadvantages of Sleeve Gastrectomy?
- Irreversible
- Inadequate weight loss/gain
- Newer technique with more unknowns
- Serious complications if a leak occurs
What is Roux-en-Y Gastric Bypass?
A malabsorptive procedure that creates a small pouch to restrict food intake and bypass portions of the small intestine
This procedure allows food to bypass the lower stomach, duodenum, and first part of the jejunum.
What are the advantages and disadvantages of roux-en-Y gastric bypass (RGB)?
Advantages
* Significant weight loss
* Greatly controls food intake
* Reversible in an emergency - though this procedure should be thought of as permanent
* Minimal diet restriction
Disadvantages
* Staple line failure
* Ulcers
* Narrowing/blockage of the stoma
* Vomiting if food is not properly chewed or eaten too quickly
* Risk of deficiencies in vitamins (B12), iron and calcium.
What is Dumping Syndrome? Can it be avoided?
Occurs when food moves too quickly from the stomach to the duodenum, also called rapid gastric emptying.
Can avoid it by changing diet.
Smaller meals and limit high sugar foods.
What are potential complications of abdominal surgery?
- Infection
- Hemorrhage
- Hernia
- Bowel obstruction
- Anastomotic leakage
- Dumping syndrome
- Nutritional deficiencies
Are there any additional disadvantages to surgery?
- High Cost
- Waiting lists
- Many eligible patients don’t want surgery
- Large amount of resources pre- and post operation (other complications)
- Potential need for body countering surgery
What are the general results from surgery?
- 40% reduction in mortality
- 50-90% reduction in incidence of diabetes
- 55% reduction in coronary artery disease
- 60% reduction in cancer (most, but perhaps ↑ colon cancer)
What psychological effects might patients experience after bariatric surgery?
- Grieve the loss of food
- Increase in self-esteem
- Changes in social circles
- Difficulty with social functions revolving around food
What is diabetes remission?
- Partial Remission: A1C <6.5% for at least 1 year without hypoglycemic agents
- Complete Remission: A1C <5.7% for at least 1 year without hypoglycemic agents
- Prolonged Remission: A1C <5.7% for at least 5 years without hypoglycemic agents
What are the effects of bariatric surgery on mortality and disease incidence?
- 40% reduction in mortality
- 50-90% reduction in incidence of diabetes
- 55% reduction in coronary artery disease
- 60% reduction in cancer
What were the findings for metabolic surgery vs. medical/ lifestyle intervention for diabetes remission?
Despite variability, surgery was found to be more effective than medical/lifestyle intervention for diabetes remission.
Decreased A1C by 2-3% (1-1.5%
medical/lifestyle groups)
What were the outcomes found from surgery, behavioural changes, and medications in BMI 30-35 kg/m2?
Surgery: A decrease in BMI of 5-7 kg/m2.
Behavioural Changes: Weight loss of 2.8 kg with additional exercise and diet changes.
Medications: Found diabetes incedence in 10 years reduced by 18%.
What are the primary mechanisms for diabetes remission with metabolic surgery?
- Decreased hunger
- Increased satiety
- Slowing digestion/absorption
- Decreased pleasantness of food
- Increased metabolic rate
How do weight loss medications work?
- Decreasing hunger
- Increasing satiety
- Slowing digestion/absorption
- Decreasing pleasantness of food
- Decreasing absorption
- Increasing metabolic rate
Which populations cannot take weight loss medications?
- BMI > 30 kg/m2
- BMI between >27 kg/m2 with comorbidities
What is Orlistat and how does it work?
A lipase inhibitor that inhibits the breakdown of fat, causing it to pass through the digestive system.
Side effects include flatulence and inability to control bowel movements.
Brand names include Xenical and Alli.
How are weight loss drugs effective?
Likely causes weight loss by slowing gastric emptying, effect on satiety (brain)… and not causing hypoglycemia.
What is Liraglutide and its effect on weight loss?
A GLP-1 analogue that inhibits feeding and may cause weight loss by slowing gastric emptying and affecting satiety
Sold under the brand name Saxenda for obesity.
What are the side effects of Liraglutide?
- Headache, dizziness
- Nausea
- Diarrhea, constipation
- Thyroid cancer (high doses in rats)?
- Pancreatitis/pancreatic cancer, currently little support of increased risk
What are the side effects of Contrave?
- Headache
- Dizziness
- Nausea
- Diarrhea
- Constipation
What is Contrave?
Combines low doses of naltrexone and bupropion. These medicines work on two separate areas of the brain that are involved in controlling eating (hunger and cravings).
Contrave is approved for use in adults with…
BMI of 30 kg/m2 or higher; OR
BMI of 27 kg/m2 or above with the presence of at least one weight-related condition such as hypertension, T2D or dyslipidemia (abnormal amounts of triglycerides, cholesterol or fat in the blood).
With PA and Contrave, a ___ calorie reduction can occur.
~500
What are general recommendations for setting weight loss goals?
Set reasonable goals; many obese individuals expect to lose 25-35% of their initial weight in about 1 year
Weight loss often plateaus and may be regained after medication is stopped.
What is the expected weight loss from Roux-en-Y gastric bypass after 36 months?
40 - 50 kg
This is generally more than weight loss from restrictive procedures.
True or False: All anti-obesity medications are covered by public drug benefit programs.
False
Medications for obesity are not covered through public drug benefit programs.
Explain the “Game Changer” double blinded trial.
1981 adults with BMI >27 + 1 co-morbidity, or >30kg/m2
Randomized to 68 weeks of a lifestyle intervention plus semaglutide or placebo.
Individuals with the semaglutide were shown to have a signifcant decrease in BW, compared to the placebo group.
In general, the malabsorptive procedures lead to ____
weight loss than the restrictive procedures after ____ months.
More; 36
What is the expected weight loss for RYGB, gastric banding, Orlistat, and Semaglutide?
RYGB: 40-50 kg
Gastric banding: 30-40 kg
Orlistat OR Liraglutide: 3-5 kg
Semaglutide: >10kg
