Obesity & weight loss management 5.3.2

Question 1

What is the medical aims of treating obesity?

Answer 1

• Keep people at the lower end of their weight range
• Eat a healthy, balanced diet
• Exercise
• Good sleep hygiene
• Stress management
• Psychological health

Question 2

What does the Australian Obesity Guidelines say about approach to weight management?

Answer 2

• Ask and assess- current lifestyle and BMI, comorbid, other factors related
• advise- promote the benefits of a healthy lifestyle and explain the benefits of weight manageent
• assist- develop a weight management program that includes interventions tailored to the individual
• arrange- regular follow up visits, referral as required and support for long term weight management

Question 3

Asking about and assessing eating and physical activity patterns?

Answer 3

Question 4

Asking about and assessing factors influencing health behaviours?

Answer 4

Question 5

What do you assess initially and monitor for weight loss management?

Answer 5

• BMI
• Waist circumference
• Blood pressure
• Fasting glucose and HbA1c
• TSH
• LFT’s
• Fasting lipids
• Sleep apnoea

Question 6

Give me some weight loss advice? lol

Answer 6

• Even small amounts of weight loss bring health benefits
  
  • including lowered cardiovascular risk, prevention, delayed progression or improved control of type 2 diabetes, and improvements in other health conditions
• Lifestyle change that includes reduced energy intake and increased physical activity has health benefits that are independent of weight loss
• Multicomponent interventions that address all three lifestyle areas related to overweight and obesity— nutrition, physical activity and psychological approaches to behavioural change—are more effective than single component interventions
• even 5-10% weight loss is clinically meaningful

Question 7

What are the goals of treatment?

Answer 7

• The goal of therapy is to prevent, treat, or reverse the complications of obesity and improve quality of life
  
  • Health benefits with weight loss of only 5% of body weight
  • Many patients have a weight loss goal of 30% or more n Often not achievable without bariatric surgery
  • With lifestyle measures only, an initial weight loss goal of 5 to 7 percent of body weight is more typical.
  • Drug and behavioural interventions n Weight loss of 10-15% is considered a very good response
• Realistic and achievable weight loss goals should be individualized and agreed upon
• Effective treatment varies from person to person

Question 8

Who is a candidate for a weight loss intervention?

Answer 8

• Low risk
  
  • BMI 25 -30 kg/m2
  • NO risk factors for CVD or other obesity-related comorbidities
  • Aim to prevent further weight gain
  • Counsel on diet and lifestyle
• Moderate risk
  
  • BMI 30-35 kg/m2 OR between 25-30 kg/m2 and with one or more risk factors for CVD (diabetes, hypertension, dyslipidaemia), or with obstructive sleep apnoea or symptomatic osteoarthritis
  • AIM weight loss
  • Diet, physical activity and behavioural modifications
  • Consider pharmacological tx
• Also consider waist circumference when looking at risk
• high risk
  
  • BMI 35-40kg/m2
• Very high risk
  
  • BMI >40kg/m2
• Both (very high and high risk) receive aggressive treatment
  
  • Intensive, multicomponent behavioural intervention
  • Pharmacologic therapy
  • Bariatric surgery

Question 9

What are goals of treatment and who to treat?

Answer 9

• everyone will benefit from
  
  • a healthy balanced diet
  • regular exercise
  • good sleep hygiene and stress management
• aim fr weught loss if
  
  • BMI>30 or BMI>27 and comorbidities (also look at WC)
• Goals of treatment:
  
  • Lifestyle measures – 5-7% weight loss
  • Drug and behavioural – 10-15% weight loss
  • Health benefits with only 5% loss
  • Have realistic and achievable goals
  • Multicomponent interventions are more effective
    
    • Diet, physical activity and psychological approaches

Question 10

Summary of initial assessment

Answer 10

• Diet
  
  • Healthy foods (unprocessed, lots of fruit and vege)?
  • Soft drinks/calorie rich beverages
  • Regular meals vs binge/snacking
• Physical activity
• Social influences
  
  • Affordability and social support
• Physical and developmental factors
  
  • Medication associated with weight gain
  • Impaired mobility or disability
• Psychological factors
  
  • Depression, PTSD, eating disorder, EtOH, smoking
• Check n BMI, WC, BP, BGL, HbA1c, TSH, LFT’s, lipids, ?OSA

Question 11

What are the 5 options/ approaches for the management of obesity?

Answer 11

1. Diet
2. Exercise
3. Behavioural modification
4. Medications
5. Surgery

Combination approach

• Dietary
• Exercise
• Behavioural modification
  
  • Case manager
  • Group/individual sessions
  • Training, feedback and support

Question 12

What is some general advice for dietary approach?

Answer 12

• Eliminate caloric beverages
• Portion control
• Self-monitoring (food diaries, activity records, selfweighing)
• Adopting a healthy long-term approach to eating
• Weight loss of 5 to 7 percent of body weight carries numerous health benefits and should be sought as an initial weight loss goal

Question 13

How can diet help weight loss management?

Answer 13

• Rate of weight loss directly related to the difference between the individuals energy intake and energy expenditure
  
  • Significant variation based on adherence and genetic factors
    
    • Men lose more, elderly lose less
• Approx 22 kcal/kg is required to maintain 1kg of body weight in a normal-weight adult
  
  • Calculated energy expenditure for a woman weighing 100 kg is approximately 2200 kcal/day
  • Variability of ±20 percent could give energy needs as high as 2620 kcal/day or as low as 1860 kcal/day
  • An average deficit of 500 kcal/day should result in an initial weight loss of approximately 0.5 kg/week
• After 3-6 months of weight loss, loss of lean mass slows the body weight response to the initial change in energy intake, thereby reducing ongoing weight loss
  
  • For weight loss to continue, further caloric restriction or increased caloric expenditure must occur

Question 14

What diets are beneficial for weight loss management? (conventionaldiets)

Answer 14

• Conventional diets are defined as those with energy requirements > 800 kcal/day
• These diets fall into the following groups
  
  • Balanced low-calorie diets and low-calorie versions of healthy diets (eg, Mediterranean and Dietary Approaches to Stop Hypertension [DASH] diets)
  • Low-fat diets (fat<30% of energy intake)
  • Low-carbohydrate and low glycemic index diets
  • High-protein diets

Question 15

What are balanced low-calorie diets and low-calorie versions of healthy diets?

Answer 15

• 1000-1500 kcal/day
• portion controlled meals
• low calorie version of health diets
  
  • mediterranean
  • DASH
• men
  
  • 1200-1600 calories
  • 5000-6700 kJ
• women
  
  • 1000-1200 calories
  • 4000-5000 KJ
• 1 calorie= 4.18 KJ

Question 16

What is a low carb or low GI diet?

Answer 16

• Low carb (60-130g) and very low carb (<60g)
  
  • More effective than low fat diets for short-term weight loss but probably not for long-term weight loss
  • If healthy fat and protein choices may have other health benefits
  • Ketosis if <50g/day carbs
    
    • rapid weight loss due to glycogen breakdown and fluid loss (rather than fat loss)
• Either
  
  • Reduce carbohydrate intake OR
  • Consume foods with lower GI (?uncertain benefit)

Question 17

Whats a high carb diet?

Answer 17

• More satiating and stimulate thermogenesis
• But limited evidence for benefit
• May improve weight maintenance

Question 18

Whats a VLCD? very low calorie diet?

Answer 18

• Energy levels between 200-800 kcal/day (836-3350kJ)
  
  • <200 kcal/day = starvation diet – not recommended!
• VLCD
  
  • Not superior to conventional diets for long-term weight loss
  • greater short term weight loss
  • Meal replacements – usually 8-16 weeks
  • Under medical supervision
• Adverse effects
  
  • Hair loss, thinning of skin, coldness, gout, ↓BMD
  • Increased cholesterol mobilisation from peripheral fat stores, gallstones
  • CI pregnancy, lactation, children, recent MI/USA
• Used for rapid weight loss for a specific purpose
  
  • Eg prior to surgery
• Monitoring required
  
  • LFT’s, lipids, FBC, Fe studies, UEC, uric acid
  • Baseline and at 6 weeks (or earlier if required (eg CKD))
  • Review medication
    
    • Esp insulin and oral hypoglycemics
  • Monitor psychological wellbeing
• Can replace all 3 meals or replace 2 meals and have 1 meal with protein, non-starchy vegetables and salad
  
  • Importance of achieving ketosis to suppress hunger
    
    • Ketone testing required
    • Avoid extra carbs (non-starchy veges or protein prn)
  • Small qty fat each day (1 tbsp olive oil) to contract gallbladder and prevent gallstones
  • Drink water when thirsty
  • Need fibre supplement
  • Wean off diet

Question 19

What is partial meal replacement?

Answer 19

• Replacing 1-2 meals with meal replacement (shake, bar, soup)
  
  • Eg Tony Ferguson®, Betty Baxter®, Kate Morgan®, Impromy® etc
  • Portion controlled, convenient, filling
• Initial assessment, goal setting, BMI/WC, membership fee, specific diet and exercise programs, weekly appointments
• meal replacements
  
  • not always nutritionally complete
  • not sustainable long term
  • still need to change eating habits

Question 20

What is alternate day fasting?

Answer 20

• 5:2 or alternate day
• Trial looked at 25% energy needs on “fast” days and 125% energy needs on “feast” days vs 75% energy needs every day (calorie restriction)
  
  • Weight loss was similar
• Some people may find fasting easier than every day calorie restriction
• other benefits

Question 21

Out of all the diets which one should you choose?

Answer 21

• Goal of diet – reduce calories consumed
• Adapt Mediterranean/DASH diet
  
  • Reduce or avoid
    
    • Refined carbohydrates, processed meats, foods high in sodium/trans fats
  • Moderation
    
    • Unprocessed red meats, poultry, eggs, milk
  • High intake
    
    • Vegetables, fruits, nuts, fish, minimally processed whole grains, legumes, yoghurt
• allows greater flexibility and personal preference in diet and may improve long-term adherence
• Mediterranean diet has also been associated with improvement in glycaemic control in diabetic patients and mortality benefits
• Although many individuals have success losing weight with diet, most subsequently regain much or all of the lost weight

Question 22

What adaptations favour weight gain?

Answer 22

• although many people have success losing weight with diet, most subsequently regain much or all of the weight lost due to the following
  
  • a reduction in energy expenditur induced by weight loss
  • changes in peripheral hormonal signas that regulate appetite
  • ghrelin which stimulates appetite, and glucose dependent insunilotropic polupepeitde, which may promote energy storage, increase after diet induced weight loss
  • other circulating mediaores that inhibit food intake (e.g. leptin, peptide YY, cholecystokinin, amylin) decrease
  • these hormonal adaptations can persist for atleast one year after diet induced weight loss, collectively conspiring against weight loss maintenacne
• exercise and behvaioural interventions are 2 important strategies to mitigate these factors

Question 23

Summary for diet

Answer 23

Question 24

Is exercise helpful in obesity management?

Answer 24

• Not as effective in promoting weight loss as diet
• But - increased physical activity helps maintain weight loss
• How much?
  
  • >30 minutes per day 5-7 days per week
  • ~150 minutes per week of vigorous activity
  • OR ~300 minutes per week of moderate-intensity activity
• To prevent weight gain and improve cardiovascular health
• A multicomponent program preferred
  
  • Aerobic and resistance training
    
    • Build up slowly
    • Adjust based on age, existing medical conditions and preferences
    • Resistance training on non-consecutive days
    • Increase incidental exercise too

Question 25

Why don’t you lose weight with exercise alone?

Answer 25

• If a patient utilizes 100 calories during exercise each day (700 calories per week), it would take roughly five weeks to utilize the energy (3500 calories) in one pound of fat
• It takes a considerable amount of time and effort to expend calories via physical activity that results in noticeable weight loss
• Adding exercise to a calorie-restricted diet may have important physiologic benefits independent of weight loss, however
  
  • As a result of any weight loss, approximately 20 percent is due to loss of lean body mass (eg, muscle mass), with the remaining 80 percent due to loss of fat
  • Increased physical activity attenuates the diet-induced loss of muscle mass, which in turn increases physical functioning and insulin sensitivity

Question 26

What are the health benefits of regular exercise?

Answer 26

• Lower risk of:
  
  • All-cause mortality, cardiovascular disease mortality, cardiovascular disease, hypertension, type 2 diabetes, adverse blood lipid profile, cancers of the bladder, breast, colon, endometrium, oesophagus, kidney, lung, and stomach, dementia
• Improved:
  
  • Cognition, QOL, sleep, bone health, physical function
• Reduced:
  
  • Anxiety, risk of depression, risk of falls, weight gain
• Weight loss when combined with calorie restriction
• Prevention of weight regain following initial loss

Question 27

Practical info to support weight MANAGEMENT through physical activity via Australian obesity guidelines?

Answer 27

Question 28

How does behavioural modifications help obesity?

Answer 28

• Cornerstone of the treatment of obesity
  
  • Aim to help patient make long-term changes in their eating behaviour by modifying and monitoring their food intake, modifying their physical activity, and controlling cues and stimuli in the environment that trigger eating
  • These concepts are usually included in programs conducted by psychologists or other trained personnel as well as many self-help groups
    
    • Mindful eating
    • Regular eating patterns
    • Avoiding situations that result in unhealthy behaviours

Question 29

What are examples of techniques to support behavioural change?

Answer 29

Question 31

What medications can be used for obesity management?

Answer 31

• Orlistat/Phentermine (duromine) /Liraglutide (saxenda)/ Bupropion with naltrexone/ Complementary medications
• Large variation in individual response to a medication
• Weight will plateau when maximum effect is achieved
• When drug therapy stops, weight gain can be expected
• Long-term use of weight-loss medication
  
  • Longest trial is 4 years with orlistat
  • Longer-term safety and efficacy not known
• Consider medication if:
  
  • BMI >30
  • BMI >27 with other cardiovascular risk factors
    
    • And have been unsuccessful losing weight through lifestyle changes

Question 33

WHat is orlistat? MOA?

Answer 33

• apparently its S3 (Pharmacist only)
• Prevents absorption of dietary fat
  
  • Expensive
  • Weight loss is modest
    
    • 2.5kg after 1 year
    • 2.8kg are 4 years
  • Treatment may reduce surrogate markers of morbidity (eg BP, total cholesterol and the ratio of total cholesterol to HDL) in some patients
    
    • Reduced risk of developing T2DM over 4 years in patients with impaired glucose tolerance at baseline
    • Positive effects on mortality have not been demonstrated
  • No longer considered 1st line therapy
• Mode of action
  
  • Inhibits GI lipases, preventing absorption of approximately 30% of dietary fat (effect seen 24-48hrs after dosing)
• CI
  
  • Cholestasis, major GI surgery, malabsorption, pancreatic enzyme deficiency, chronic pancreatitis
  • <18years, eating disorder, pregnant/BF (GP referral)
• Precautions
  
  • Vitamin deficiency (↓ fat soluble vitamins (ADEK))
  • Caution nephrolithiasis, CRF (↑oxalate excretion)
  • Active PUD, post-surgical adhesions
  • Significant cardiac, renal, hepatic, GI, endocrine, psychiatric, neurological disorder (GP referral)
• Adverse effects
  
  • ↑fat in stool à flatus, faecal urgency/incontinence, loose oily stools (minimise fat in diet)
  • Headache, fatigue
  • Rare
    
    • Hepatitis, liver failure, pancreatitis, allergic skin reactions
• Dose
  
  • Oral – 120mg tds with main meals
• Counselling
  
  • Take with (or up to 1 hour after) meals
  • Do not take if meal missed or doesn’t contain fat
  • Eat a low calorie diet high in fruit and vegetables
    
    • <30% calories as fat
  • encourage physical activity
• add a vit supplement esp if >1 year of tx
  
  • Separate from orlistat by >2 hours

Question 34

What are the drug interactions for orlistat?

Answer 34

• 97% of orlistat and metabolites faecal elimination
• Warfarin
  
  • Caution/close monitoring
  • Reduced vitamin K absorption↑INR
• Ciclosporin
  
  • ↑ monitoring due to ↓ plasma concentrations
• Hypoglycemics
  
  • Improved metabolic control during long-term tx –> may need reduced doses of insulin or oral hypoglycemics
• COC
  
  • Use additional contraception – breakthrough bleeding and contraceptive failure reported
• Amiodarone
  
  • ↓ effect possible
• Levothyroxine
  
  • Monitor TFT’s – increased T4 dose may be required

Question 35

What is phentermine (duromine)?

Answer 35

• Sympathomimetic with CNS stimulatory effects, increasing energy expenditure and causing early food satiety
• indication
  
  • Adjunct to lifestyle modification in obese adults (BMI >30 or >25 with other cardiovascular risk factors)
  • Short-term use
• Contraindications?
  
  • Hyperthyroidism, hx drug misuse, PUD, prostatic hypertrophy, epilepsy, cardiac or cerebrovascular disease, pregnancy, BF, <18years, elderly
• precautions?
  
  • Acute angle-closure glaucoma crisis rarely precipitated
  • Renal impairment – use a lower dose, titrate carefully
• Adverse effects
  
  • Common
    
    • CNS stimulation (insomnia, restlessness, agitation, tachycardia, arrhythmias, hypertension, diarrhoea, vomiting)
    • Headache, rash, urinary frequency, impotence
  • Rare
    
    • Pulmonary hypertension, seizures, psychosis, withdrawal sx on cessation
    • ? valvular heart disease (in combination with fenfluramine)
• dose
  
  • Adult, oral 15 mg once daily at breakfast
  • Increase if required up to a maximum of 40 mg once daily
  • Short-term treatment (4–6weeks -max 12 weeks)
• drug interactions
  
  • May ↑ BP – avoid other medications that ↑BP n Can contribute to serotonin toxicity à SS n Avoid within 14 days of a MAOI
• practice points
  
  • May be subject to misuse
  • Most prescribed weight loss medication in the USA
  • –> ~6-7kg weight loss over 3 months
  • ~$80- per month

Question 36

What are some withdrawn medications?

Answer 36

• Sibutramine (SNRI) – withdraw–>higher risk of MI
• Phenylpropanolamin–> small risk haemorrhagic stroke

Question 37

Liraglutide?

Answer 37

• Mode of action
  
  • Analogue of glucagon-like peptide-1 (an incretin)
  • ↑ glucose-dependent insulin secretion and suppresses inappropriate glucagon secretion
  • Delays gastric emptying, which slows glucose absorption and ↓ appetite
• Indications
  
  • T2DM
  • Adjunct to lifestyle modification in obesity (BMI >30) or in BMI >27 with at least 1 weight-related comorbidity
• Precautions
  
  • Treatment with a sulfonylurea/insulin—↑ risk of hypoglycaemia
  • Severe GI disease, eg gastroparesis, dumping syndrome
  • History of pancreatitis with a GLP-1 analogue—contraindicated n
  • Increases the risk of gall bladder disease
• Adverse effects
  
  • Common – N, V, D, constipation, dyspepsia, GORD, abdo pain, fatigue, injection site reactions, small ↑HR, hypoglycaemia (mainly when used with sulphonylurea/insulin)
  • Infrequent - cholelithiasis, cholecystitis
  • Rare – pancreatitis, allergic reactions, ↑Cr, AKI, worsen CRF, ?↑ risk of Ca (avoid in MEN2 or hx thyroid Ca)
• Dosage
  
  • Saxenda®, adult, SC, initially 0.6 mg once daily
  • Increase dose in increments of 0.6 mg daily at intervals of at least 1 week
  • Maintenance dose 3 mg daily
• Counselling
  
  • Tell Dr ASAP if sudden unexplained severe abdominal pain
  • Commonly causes nausea, and sometimes vomiting or diarrhoea, when you start taking it but this usually reduces and stops within a short time
  • If affected, drink plenty of fluids to avoid dehydration

Question 38

What are some practice points for liraglutide?

Answer 38

• stop treatment if weight loss is less than <5% of initial weight after 12 weeks at the maintencance dose
• weight loss is generally plateaued after 8-9 months
• weight was regained when tx was stopped
• no evidence for efficacy and safety >1 year of treatment
• Evidence for an effect of liraglutide on the complications of obesity (eg cardiovascular outcomes) is also lacking
• Liraglutide’s effect on weight is dose-dependent
• Option for obese T2DM patients
• Mean weight loss ~4-7kg
• Non-PBS - $$200-400/month

Question 39

What are bupriopion with naltrexone?

Answer 39

• Contrave® n Bupropion 90mg + naltrexone 8mg CR
• Non-PBS $$- expensive
• moa
  
  • Unclear what benefit naltrexone adds
  • Effects in nicotine dependence may be due to inhibition of neuronal reuptake of dopamine and noradrenaline
• INDICATION
  
  • Weight management in adults with a BMI >30 or BMI >27 with other cardiovascular risk factors (adjunct to lifestyle modification)

Question 40

whAT are the CI, pre cautions and adverse effects associated with Bupropion with naltrexone?

Answer 40

• CI
  
  • MAOI within 14 days, hx seizures, CNS tumour, hx eating disorder, EtOH/drug withdrawal, end stage CRF, hepatic impairment, pregnancy/BF, chronic opioid tx
• Precautions
  
  • ↑BP, bipolar (may à mania), reduce dose in renal impairment and elderly
• Adverse effects
  
  • Common - anorexia, nausea, vomiting, dry mouth, diarrhoea, abdominal pain, constipation, insomnia, nightmares, dizziness, concentration difficulties, agitation, anxiety, tremor, headache, fever, rash, itch, urticaria
  • Infrequent - palpitations, tachycardia, hypertension, chest pain, confusion
  • Rare - seizures (esp if high dose), paraesthesia, hallucinations, delusions, paranoid ideation, parkinsonism, depression, aggression, anaphylaxis, angioedema, Stevens-Johnson syndrome, serum sickness, jaundice, hepatitis

Question 41

Whats the dose of Bupropion with naltrexone and some counselling points?

Answer 41

• adult
  
  • Initially 1 tablet once daily in the morning for 1 week
  • Then 1 tablet twice daily for the next week
  • Then 2 tablets in the morning and 1 tablet in the evening for the third week
  • Then 2 tablets twice daily
    
    • Take with food, swallow whole
  • Renal impairment
    
    • CrCl 15–60 mL/minute, initially 1 tablet once daily in the morning for 1 week, then 1 tablet twice daily
  • Stop treatment if weight loss is <5% of initial weight after 16 weeks
• counselling
  
  • drink only small quantities of alcochol- risk of seizures
  • false positives with some UDs?? wot is UD (for amphetamines)
  • monitor for LFT

Question 42

What are some drug interactions for bupropion and naltrexone?

Answer 42

• Drug interactions
  
  • Bupropion
    
    • Strong CYP2D6 inhibitor
    • Metabolised by CYP2B6
  • Naltrexone – blocks opioid receptors
• practice points
  
  • May suppress appetite; clinical trials showed modest weight loss after 1 year
    
    • Mean loss of around 4–5 kg (3 kg in patients with T2DM)
    • Weight loss plateau after ¬6mths
    • Efficacy and safety >1year not known
  • GI adverse effects may limit compliance
  • Uncertainty regarding its long-term safety (particularly cardiovascular outcomes)
  • Could be an option for the obese patient who also wants to quit smoking – not first line therapy
  • ~$225- per month

Question 43

What are some medications for comorbidities that can cause weight loss?

Answer 43

• Metformin
• Fluoxetine
• Topiramate
• GLP-1 agonists

Question 44

Can complementary medicines be useD?

Answer 44

• little evidence to support complementary medicines for weight loss
• risk of harm

Question 45

What is inappropriate drug treatment for weight loss?

Answer 45

• Bulk forming laxatives (to improve satiety)
• Laxative abuse –> severe fluid and electrolyte imbalance
• Levothyroxine – to ↑BMR – contraindicated–> arrhythmias, HTN, bone disease)
• Diuretics –> fluid loss and electrolyte imbalance

Question 46

What medications are used OVERSEAS for weight loss managament?

Answer 46

• Phentermine/Topiramate combination therapy
  
  • Abuse potential (phentermine)
  • Teratogenic, mood disturbance, metabolic acidosis (topiramate)
• Lorcaserin
  
  • Serotonin 2C receptor agonist
  • Approved for long-term use
  • Avoid combination with other serotonergic medications
  • May cause dependence/euphoria at higher doses
  • ? increased risk of cancer

Question 47

When do we consider medication for patients for weight loss?

Answer 47

• BMI >30
• BMI >27 with other cardiovascular risk factors
• And have been unsuccessful losing weight through lifestyle changes

Question 48

When is Bariatric surgery considered?

Answer 48

• These interventions are likely to be used sequentially—for example, starting with a very low-energy diet to achieve weight loss, then using medications to help counter the hormone changes and increased hunger that follow weight loss
• Bariatric surgery is not generally an immediate consideration unless:
  
  • other interventions have not been successful
  • other interventions are contraindicated
  • a person’s BMI is > 50 kg/m2
• New weight loss medications are being developed and trialled. It can be envisaged that in the future, the combination of a very low-energy diet followed by pharmacotherapy may be a reasonable alternative to bariatric surgical procedures

Question 49

Summary of effects of weight management interventions?

Answer 49

Question 51

What are some types of bariatric surgery?

Answer 51

• LAGB (Laparoscopic adjustable gastric banding)
  
  • Involves placing a band around the stomach near its upper end to create a small pouch. This restricts intake of food. The band can be tightened or loosened over time to change the extent of restriction n
• Sleeve gastrectomy
  
  • Involves removing the greater portion of the fundus and body of the stomach, reducing its volume from up to 2.5 L to about 200 mL. This procedure provides fixed restriction and does not require adjustment like LAGB
• Roux-en-Y gastric bypass (RYGB)
  
  • Is a combination procedure in which a small stomach pouch is created to restrict food intake and the lower stomach, duodenum and first portion of the jejunum are bypassed to produce modest malabsorption of nutrients and thereby kilojoule intake

Question 52

How do we approach bariatric surgery? What are the outcomes?

Answer 52

• Better outcomes are achieved when a multidisciplinary team (e.g. including bariatric physician, bariatric nurse, dietitian, exercise physiologist and psychologist) is involved
• The degree of weight loss is high
  
  • Approximately 20–30% of body weight in people with a BMI > 35 kg/m2

Question 53

What are the health benefits of bariatric surgery?

Answer 53

• Bariatric surgery associated with
  
  • ↓ in HTN and lipid profiles
  • Improved glycemic control or resolution of T2DM
  • Reduced mortality
  • Improvement in renal function in CKD
  • Improvement in GORD
  • Improved LFT’s/inflammation in ppl with NAFLD
• Unclear whether improvement in comorbid conditions with bariatric surgery are due to the weight loss itself, or due to the different changes in hormone balance, metabolism, pressure dynamics and mechanics that each type of bariatric surgery produces

Question 54

What are some adverse events with bariatric surgery?

Answer 54

• surgery associated with significant risks - eg
  
  • May require revision surgery
  • Leak at staple line
  • Infection
  • VTE
  • Bleeding
• Need to consider
  
  • Strict eating plans
  • Lifelong vitamin supplementation
  • Psychological effects of surgery
  • Risk of regaining weight – need continued behavioural, diet and exercise interventions

Question 55

What is the role of the pharmacist in bariatric surgery?

Answer 55

• Consider absorption of medications post-gastrectomy
  
  • Bariatric surgery may alter the absorption, distribution, metabolism and/or elimination of orally administered medication via changes to the gastrointestinal tract anatomy, body weight, and adipose tissue composition
  • Reduced food intake
    
    • Eg Rivaroxaban 15mg+20mg – food ↑BA
  • Reduced absorptive surface
    
    • ↑pH
      
      • Does drug need acid for absorption
      • –> ↓ solubility of acidic medication
  • how much drug is absorbed in the stomach
    
    • ?is any of the small intestine removed/bypassed
    • ↓ mixing with bile salts –>↓ absorption lipophilic meds
    • Avoid SR/EC products
    • ↑ risk AE’s (eg avoid NSAIDS, bisphosphonates)
  • Change in Vd with weight loss

Question 56

What is the role of the pharmacist in bariatric surgery? part 2

Answer 56

• Look at each medicine individually
  
  • Go back to first principles
    
    • Consider post-op anatomy and medication PK/PD
  • Monitor and adjust
    
    • Liquids
      
      • May have to stagger doses if large volume
      • Aqueous ↑rapidly absorbed vs oily/suspn vs tablets
  • Sublingual, topical, injectable, rectal options
  • Halve or crush tablets (esp if >10mm)
  • Avoid effervescent tablets
  • Avoid formulations that contain sucrose, corn syrup, lactose, maltose, fructose, honey or mannitol to minimize the risk of dumping syndrome
    
    • OCP – monitoring not an option – use barrier method
  • PI, Micromedex, Don’t rush to crush

Question 57

What are some examples of drygs with potential for decreased absorption in patients who have undergone bariatric surgery?

Answer 57

Question 58

Summary- obesity

Answer 58

• Pandemic – globesity
  
  • Worldwide obesity has nearly tripled since 1975
  • 67% Australian adults are overweight/obese
• Use BMI and WC to measure if overweight
  
  • BMI >25 and WC ≥102 cm for men & ≥88 cm for women
  • Can be variation based on genetics & muscle mass

Question 59

Summary- causes of obesity

Answer 59

• complex interplay of many factors
• Diet
  
  • increased calorie consumption, infant feeding practices
• Exercise
  
  • Reduced physical activity (may be unable to exercise)
• Genetic
  
  • Strong predictor of future weight
• Psychological
  
  • Link with psychological illness
• Behavioural
  
  • Binge eating
• Social and Environmental
  
  • Obesogenic environment (junk food, sedentary lifestyle, convenience food, eating as social activity)
• Economic
  
  • Increased risk in lower socioeconomic areas, ATSI, CALD

Question 60

Summary- causes of obesity

• secondary causes

Answer 60

• Medication
• atypical antipsychotics for BPAD
• clozapine, olanzapine
• beta adrenergic blockers for HTN, anxiety
  
  • esp propanalol
• insulin for DM
• lithium for BPAD
• pizotifen for migrane and cluster headache
• sodium valproate for epilepsy and psychosis
• sulphonylureas for T2DM
  
  • chlorpropamide, glibenclamide, glimepiride, glipizide
• pioglitazone for T2DM
• TCAs for depression
  
  • amitriptyline
• anabolic steroids
• various endocrine disorders

Question 61

Summary- physiology of obesity

Answer 61

• Weight loss not as simple as calories in < calories out
  
  • Complex –ve feedback and role of hormones
  • Body defends itself against weight loss
    
    • Continued xs calories –>upward resetting of defended level of body weight
      
      • Hormones–> ↑hunger and ↓energy expenditure
• Many unknowns
  
  • ? Role of high fat diet, emulsifiers, brown fat
  • Microbiome

Question 62

Summary- risks associated with obesity?

Answer 62

• Obesity associated with:
  
  • Reduced life expectancy (worsens with ↑BMI)
    
    • Exercise has a protective effect
  • >230 comorbidities and complications of obesity!
    
    • Even moderate weight loss will improve most of these
    • Eg diabetes, dyslipidemia, HTN, stroke, VTE, cancer, OA, gout, GORD, NAFLD, cholelithiasis, infertility, pregnancy risk, sexual dysfunction, CKD, kidney stones, incontinence, depression, dementia, OSA, infections, skin changes
• Huge individual and societal cost of obesity

Question 63

Summary- goals of tx and who to treat

Answer 63

• Everyone will benefit from:
  
  • Healthy balanced diet
  • Regular exercise
  • Good sleep hygiene and stress management
• Aim for weight loss if:
  
  • BMI >30 or BMI>27 and comorbidities (also look at WC)
• Goals of treatment:
  
  • Lifestyle measures – 5-7% weight loss
  • Drug and behavioural – 10-15% weight loss
  • Health benefits with only 5% loss
  • Have realistic and achievable goals
  • Multicomponent interventions are more effective
    
    • Diet, physical activity and psychological approaches

Question 64

Summary-initial assessment

Answer 64

• Diet
  
  • Healthy foods
  • Soft drinks/calorie rich beverages
  • Regular meals vs binge/snacking
• Physical activity
• Social influences
  
  • Affordability and social support
• Physical and developmental factors
  
  • Medication associated with weight gain
  • Impaired mobility or disability
• Psychological factors
  
  • Depression, PTSD, eating disorder, EtOH, smoking
• Check
  
  • BMI, WC, BP, BGL, HbA1c, TSH, LFT’s, lipids, ?OSA

Question 65

Summary- diet

Answer 65

• Key points
  
  • 5-7% weight loss
  • Eliminate caloric beverages
  • Portion control
  • Healthy long-term approach to eating
    
    • Balanced low calorie diet
      
      • Eg Mediterranean/DASH
        
        • Lots of fruit and vegetables
        • Avoid processed food
      • As lose weight then need further caloric restriction to keep losing weight
      • Hormonal adaptations make weight loss very hard
  • VLCD
    
    • Useful for rapid weight loss prior to surgery
    • Adverse effects and needs regular monitoring

Question 66

Summary- exercise

Answer 66

• Not as effective in promoting weight loss as diet
• But - increased physical activity helps maintain weight loss
  
  • Exercise also has significant benefits on morbidity and mortality
• How much?
  
  • >30 minutes per day 5-7 days per week
    
    • ~150 minutes per week of vigorous activity OR
    • ~300 minutes per week of moderate-intensity activity
  • To prevent weight gain and improve cardiovascular health
  • A multicomponent program preferred
    
    • Aerobic and resistance training

Question 67

Summary- medication

Answer 67

• Large variation in individual response to a medication
• Weight will plateau when maximum effect is achieved
• When drug therapy stops, weight gain can be expected
• Consider medication if:
  
  • BMI >30
  • BMI >27 with other cardiovascular risk factors
    
    • And have been unsuccessful losing weight through lifestyle changes

Question 68

Summary- which medicines?

Answer 68

• Orlistat (S3)
  
  • Prevents absorption of dietary fat
    
    • Modest weight loss
    • May reduce risk of BP, chol, T2DM
    • AE’s – flatus, oily rectal leakage. Caution DI’s
• Phentermine
  
  • sympathomimetic
    
    • Short-term use
    • AE’s – insomnia, agitation, hypertension, SS
• Liraglutide
  
  • GLP-1 analogue also used in T2DM
  • AE’s – nausea, pancreatitis, ?thyroid Ca. Subcut injection, $$
• Bupropion with naltrexone
  
  • May be option in obese pt quitting smoking, $$
  • N,V, constipation, headache, ↑BP and HR, seizures –> May àmania in bipolar, caution suicidal ideation

Question 69

Summary- bariatric surgery

Answer 69

• Significant weight loss (20-30% body weight) associated with bariatric surgery
  
  • –> improvements in some cardiovascular and metabolic risk factors, and type 2 diabetes
    
    • LAGB (Laparoscopic adjustable gastric banding)
    • Sleeve gastrectomy
    • Roux-en-Y gastric bypass (RYGB)
• But – surgery associated with risks as well
  
  • Leak, infection, bleeding, VTE, revision surgery
  • Strict eating plans, lifelong supplements
• Role of the pharmacist
  
  • Manage medications when patient NBM
  • Post-op
    
    • PPI, analgesia, antinauseants, VTE px, vitamins
    • Review other medications
      
      • Will absorption be affected?
        
        • Effect of food, pH, site of absorption, AE’s
      • Will medication still be required?
    • Liquids (watch volume), inj, rectal, topical, subling, crush
    • Avoid effervescent, SR, EC, irritant, sweet (dumping)