Weight loss: Drugs & Surgery Flashcards
List the categories of bariatric surgery
Restrictive, Malabsorptive, and Mixed procedures
How many individuals with a BMI >35kg/m2 are eligible for bariatric surgery?
1 in 171 individuals
What are some issues highlighted in the Obesity Canada Report Card?
▪ Certified bariatric designation is growing.
▪ No official guidelines or policies for obesity treatment and management.
▪ Lacking interdisciplinary teams in primary care.
▪ Patients often cover costs of meal replacements ($1000-2000/month).
▪ Obesity medications are not covered through public drug benefit programs.
▪ Limited access to surgery with long wait times.
What BMI qualifies a patient for bariatric surgery, or what BMI with comorbidity?
A BMI > 40 kg/m2, or a BMI between 35-40 kg/m2 with a major medical comorbidity
List examples of obesity-related comorbidities that may warrant bariatric surgery.
Diabetes, hypertension, cardiovascular disease, obstructive sleep apnea
What are the eligibility requirements beyond BMI for bariatric surgery?
▪ Strong desire for weight loss
▪ Understanding of the impact of surgery
▪ Comorbidities that are known to improve with weight loss
▪ Severe sleep apnea
▪ Severe diabetes
▪ Physical problem interfering with lifestyle
What are the contraindications for bariatric surgery?
▪ >60 years of age
▪ Medical conditions making surgery at “high risk”
▪mPregnancy
▪ Genetic conditions (e.g. Prader-Willi)
▪ Certain mental health disorders (suicide attempts)
▪ Substance/alcohol abuse
▪ Poor attendance + refusal to make lifestyle changes
▪ Unable to comprehend advice
What services does the Edmonton Adult Bariatric Specialty Clinic provide?
Medical, psychological, and surgical interventions for weight managemen
What does the initial clinic assessment at the Edmonton Adult Bariatric Specialty Clinic determine?
Patient-specific barriers to weight management
What interventions are included in an individualized care plan at the Edmonton Adult Bariatric Specialty Clinic?
▪ Behavior modification
▪ Counseling for nutrition, physical activity, and mental health
▪ Drug treatment and/or bariatric surgery
What is the primary mechanism of restrictive bariatric procedures?
Restricting the amount of food the stomach can hold without interfering with normal digestion
How do restrictive procedures affect digestion?
They do not interfere with normal digestion
What is the primary mechanism of malabsorptive bariatric procedures?
Combining stomach restriction with a partial bypass of the small intestine to reduce calorie and nutrient absorption
List 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 are the disadvantages of Adjustable Gastric Banding (AGB)?
▪ >5% percent failure rate
▪ Slower initial weight loss
▪ In some cases, weight loss may be less pronounced than other surgeries
▪ Less improvement of diabetes than with bypass
List the advantages of Sleeve Gastrectomy.
▪ No insertion of foreign objects
▪ Reduces food intake (removes Ghrelin Cell mass: lower hunger)
▪ No malabsorption of nutrients
▪ Low potential for leakage
What are the disadvantages of Sleeve Gastrectomy?
▪ Irreversible
▪ Inadequate weight loss/gain
▪ Newer technique… more unknown. Stretch of sleeve?
▪ Complications are rare but serious – if a leak occurs, takes months to resolve
How does Roux-en-Y Gastric Bypass (RGB) work?
A small pouch is created to restrict food intake, and a Y-shaped section of the small intestine is attached to the pouch to bypass the lower stomach, duodenum, and first portion of the jejunum
List the advantages of Roux-en-Y Gastric Bypass (RGB).
▪ Significant weight loss
▪ Greatly controls food intake
▪ Reversible in an emergency - though this procedure should be thought of as permanent
▪ Minimal diet restriction
What are the disadvantages of Roux-en-Y Gastric Bypass (RGB)?
▪ 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)
What is dumping syndrome and how can it be avoided?
Dumping syndrome involves feelings of hypoglycemia and can be avoided by changing diet, eating smaller meals, and limiting high sugar foods
List potential complications of abdominal surgery in general.
▪ Infection
▪ Hemorrhage
▪ Hernia
▪ Bowel obstruction
▪ Anastomotic leakage
▪ Dumping syndrome
▪ Nutritional deficiencies
▪ Increased risk of death in first 3 months (including increased risk of suicide)
What are other disadvantages of bariatric 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 psychological effects might occur after bariatric surgery?
▪ Grieve the loss of food
▪ Increase in self-esteem and self-confidence
▪ Changes in social circles
▪ Difficulty with social and business functions that revolve around food
▪ Resentment to suddenly improved social acceptance
What supports would someone getting bariatric surgery need?
Before surgery, after surgery, psychological, nutrition, exercise, skin flap surgery.
What are the general results from bariatric surgeries in terms of mortality and disease reduction?
▪ 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)
How effective is bariatric surgery at improving diabetes compared to nonsurgical interventions?
Bariatric surgery is more effective at improving diabetes in the short term (up to 2 years) than nonsurgical interventions
How rapidly does diabetes improvement start after bariatric surgery?
Rapidly, often before significant weight loss has occurred
What BMI range is now being considered for metabolic surgery in patients with inadequately controlled diabetes?
As low as 30kg/m2 or 27.5kg/m2
What are the criteria for partial remission of diabetes according to the American Diabetes Association?
▪ Blood glucose below diabetes diagnosis thresholds: A1C <6.5%
▪ At least 1-year duration
▪ No hypoglycemic agents
What are the criteria for complete remission of diabetes according to the American Diabetes Association?
▪ Blood glucose in normal range: A1C <5.7%
▪ At least 1-year duration
▪ No hypoglycemic agents
What are the criteria for prolonged remission of diabetes according to the American Diabetes Association?
▪ Blood glucose in normal range: A1C <5.7%
▪ At least 5 years duration
▪ No hypoglycemic agents
How does metabolic surgery compare to medical/lifestyle intervention for diabetes remission?
Surgery is more effective than medical/lifestyle intervention for diabetes remission
What A1C decrease can be expected with surgery?
Decrease A1C by 2-3%
Are anti-obesity medications covered by provincial/territorial formulary programs?
NO
What percentage of individuals with private health insurance have coverage for anti-obesity medications?
Only 10%
How might weight loss medications work?
▪ Decreasing hunger
▪ Increasing satiety
▪ Slowing digestion/absorption
▪ Decreasing pleasantness of food
▪ Decreasing absorption
▪ Increasing metabolic rate
▪ Increasing physical activity
What BMI qualifies a patient for weight loss medication, or what BMI with comorbidity?
A BMI > 30 kg/m2, or a BMI between >27 kg/m2 with comorbidities such as sleep apnea or diabetes
How does Orlistat (Xenical) work?
It is a lipase inhibitor that inhibits the breakdown of fat so it passes directly through the digestive system
What are the side effects of Orlistat?
Flatulence and inability to control bowel movements
What are the effects of Orlistat on body weight and cholesterol?
▪ Body weight -2.12kg
▪ Cholesterol – 0.30mmol/L
▪ LDL – 0.27mmol/L
▪ HDL – 0.034 mmol/L
▪ TG -0.09mmol/L
How does Liraglutide (Saxenda) work?
It is a GLP-1 analogue that likely causes weight loss by slowing gastric emptying and affecting satiety in the brain, without causing hypoglycemia
What are the side effects of Liraglutide (Saxenda)?
Headache, dizziness, nausea, diarrhea, constipation, thyroid cancer (in rats), and potential pancreatitis/pancreatic cancer
What are the arguments against Liraglutide (Saxenda)?
Advocacy groups have argued to remove it from the market due to the risk of thyroid cancer and pancreatitis outweighing benefits, and the long-term impact is not well known
What is Contrave composed of and how does it work?
Combines low doses of naltrexone (for alcohol and opioid dependency) and bupropion (antidepressant/smoking cessation) to work on areas of the brain controlling hunger and cravings
For whom is Contrave approved in Canada?
Adults with a BMI of 30 kg/m2 or higher; or a BMI of 27 kg/m2 or above with the presence of at least one weight-related condition such as hypertension, type 2 diabetes, or dyslipidemia
What were the results of the clinical trials for Contrave?
60% of patients lost 5% or more of their body weight and kept it off for 56 weeks, in conjunction with diet and exercise, compared to 23% in the placebo group
What are the general recommendations for weight loss goals?
Set reasonable weight loss goals, as patients often expect to lose 25-35% of their initial weight in about 1 year, which is often impossible
What generally happens when weight loss medication is stopped?
Weight loss will plateau and is often regained
What are the typical weight loss outcomes after 36 months for Roux-en-Y gastric bypass (RYGB)?
40-50 kg
What are the typical weight loss outcomes after 36 months for Adjustable gastric banding?
30-40 kg
What are the typical weight loss outcomes after 36 months for Medications like Orlistat or Liraglutide?
3-5 kg
