THE STRUGGLE IS REAL

(1)

THE STRUGGLE IS REAL –

WHAT TO DO WHEN YOU FEEL LIKE

YOU’VE DONE IT ALL

Scott Kahan, MD, MPH, FTOS

Director, National Center for Weight and Wellness

Johns Hopkins Bloomberg School of Public Health

(2)

The Struggle is Real –

What to Do When You Feel Like You’ve Done it All

• Why not “just eat less and exercise more?”

• What does it mean when we say that we’ve done it all?

• Effective, guideline-recommended treatment options

(3)

Insulin Amylin Leptin PYY CCK GLP-1 Ghrelin 10 0 0 8 18 26 36 44 52 62 Weeks 209 198 187 176 We ig ht 40 20 0 0 30 60 120 180 240 Hung er / Dr iv e t o Ea t

Week 0 Week 10 Week 62

(4)

Guideline-Recommended Treatment Categories

(5)

Utilization of Guideline-Recommended Treatments

0 20 40 60 80 100

Total eligible IBT Obesity

(6)

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Why Aren’t Recommended Treatments Used?

• Misperceptions and confusion about obesity

• Misperceptions and confusion about obesity treatments

• Lack of HCP training in obesity

• Trustworthy and informed resources

(9)

Obesity is a disease (% Agreement)

My weight loss is completely my responsibility

(10)

Guideline-Recommended Treatment Categories

(11)

Guideline-Recommended Treatments:

Intensive Behavioral Counseling

• Comprehensive behavioral counseling program

of at least 6 months, delivery by trained provider(s)

• Gold standard is on-site, “high-intensity,” and

comprehensive counseling

• Can be individual or group-based

• At least 1 year of ongoing care

(12)

Guideline-Recommended Treatments:

Intensive Behavioral Counseling

(13)

• Adjunct to diet, exercise, and behavioral counseling

• Unable to lose/maintain weight

• Age > 18 years

• BMI > 30 (or > 27 with weight-related health conditions)

• Meet appropriate indications

• Not pregnant or breastfeeding

(14)

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Guideline-Recommended Treatments:

Obesity Medications

Placebo

(17)

Orlistat _{topiramate ER}Phentermine/ Naltrexone/_bupropion Liraglutide_3.0mg Semaglutide _2.4mg Waist



Blood pressure







Heart rate



-



LDL Cholesterol



HDL Cholesterol



Triglycerides



Blood sugar





Diabetes







(18)

(19)

• BMI > 40 kg/m

2

(or > 35 with health conditions)

• Lower weights may be appropriate in some people with

difficult-to-control diabetes

(20)

Sleeve

Gastrectomy

Roux-en-Y

Gastric Bypass

Gastric

Band

(21)

(22)

Combining Recommended Treatments

Medication Surgery

25% BWL

(23)

The Struggle is Real –

What to Do When You Feel Like You’ve Done it All

• Why not “just eat less and exercise more?”

• What does it mean when we say that we’ve done it all?

• Effective, guideline-recommended treatment options

(24)

The Struggle is Real –

What to Do When You Feel Like You’ve Done it All

• Many factors impact eating and exercising; managing

obesity often requires more than just “willpower”

• What does it mean when we say that we’ve done it all?

• Effective, guideline-recommended treatment options

(25)

The Struggle is Real –

What to Do When You Feel Like You’ve Done it All

• Many factors impact eating and exercising; managing

obesity often requires more than just “willpower”

• Beware of what you read, see, and hear about weight loss,

as much of it is bogus, and some may be harmful

• Effective, guideline-recommended treatment options

(26)

The Struggle is Real –

What to Do When You Feel Like You’ve Done it All

• Many factors impact eating and exercising; managing

obesity often requires more than just “willpower”

• Beware of what you read, see, and hear about weight loss,

as much of it is bogus, and some may be harmful

• There are well-studied, scientific, and effective treatment

options if self-management hasn’t been enough

(27)

THE STRUGGLE IS REAL –

WHAT TO DO WHEN YOU FEEL LIKE

YOU’VE DONE IT ALL

Scott Kahan, MD, MPH, FTOS

Director, National Center for Weight and Wellness

Johns Hopkins Bloomberg School of Public Health

(28)

“

THE STRUGGLE IS REAL – WHAT

TO DO WHEN YOU FEEL LIKE

YOU’VE DONE IT ALL

”

Christopher D. Still, DO, FACP, FTOS Professor of Medicine

Department of Clinical Sciences

Geisinger Commonwealth School of Medicine

Medical Director, Center for Nutrition & Weight Management Director, Geisinger Obesity Institute

(29)

(30)

Healthy Eating Pattern

Components of an Effective Obesity

Management Program

Surgery or Medications Physical Activity Behavior Modification

Wadden TA, Foster GD. Behavioral treatment of obesity. Med Clin North Am. 2000;84:441-461.

(31)

Benefits of Modest Weight Loss

Greater Benefits with Greater Weight Loss

Measures of glycemia1

-3%

Triglycerides1

HDL cholesterol1

-5%

Systolic and diastolic blood pressure

Hepatic steatosis measured by MRS2

Measures of feeling and function:

Symptoms of urinary stress incontinence3

Measures of sexual function4,5

Quality of life measures(IWQOL)6

NASH Activity Score measured on biopsy7

-10%

Apnea-hypopnea index8

Reduction in CV events, mortality, remission of T2DM

_-15%

1. Wing et al. Diabetes Care 2011;34:81-1486. 2. Lazo et al. Diabetes Care 2010;33:2156–63.3. Phelan et al. Urol. 2012;187:939-44. 4. Wing et al. Diab Care 2013;36:2937-44. 5. Wing et al. Journal of Sexual Medicine 2010 ; 7:156-65. 6. Crosby, Manual for the

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Diet and Lifestyle1 Gastric Band2 Gastric Bypass or Sleeve2 Lifestyle plus Obesity Drugs

Patients with low risk should have lower intensity, less risk approaches.

Higher risk approaches are justified when patients have more complicated obesity.

1.Jensen et al. Circulation 2014;129(25 Suppl 2):S102-38.

2.Courcoulas et al. JAMA 2013;310:2416-2425.

3.LABS consortium. N Engl J Med 2009;361:445-54.

From LABS3_{: Perioperative DVT, thromboembolism or death 1% for} gastric band 5% for bypass

Weight Management

Intensification Options

0% 3% 8% 32%

Mean Weight Loss

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Bariatric Surgery Criteria

With ≥1 severe obesity-associated comorbidity (eg, diabetes or OSA) With no comorbidities BMI: <18.5 18.5-24.9 25.0-29.9 3 BMI >35 >40 http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi.

(35)

Resolution of Comorbidities

Pulmonary disease Abnormal function Obstructive sleep apnea Hypoventilation

syndrome

Nonalcoholic fatty liver disease Steatosis

Steatohepatitis Cirrhosis

Coronary heart disease

Diabetes Dyslipidemia Hypertension 69% resolved Gynecologic abnormalities Abnormal menses Infertility

Polycystic ovarian syndrome Osteoarthritis

Skin

Gall bladder disease

Cancer

Breast, uterus, cervix, colon, esophagus, pancreas, kidney, prostate

Phlebitis 95% resolved

Venous stasis

Gout72% resolved

(36)

Sleeve Gastrectomy

Most Common Bariatric Procedures

Roux-en-Y

Gastric Bypass DuodenalSwitch

96% performed laparoscopically Average length of stay – 1.2 days

Madsbad S, et al. Lancet Diabetes Endocrinol. 2014;2(2):152-64.

(37)

Sleeve Gastrectomy

• Bariatric procedure originally as

part of BPDDS, now used as a

first stage or stand alone if

patient loses enough weight

• Remove part of stomach,

creating a sleeve from

esophagus to antrum

(38)

Roux-en-Y gastric bypass (RYGB)

Ghrelin GLP-1 PYY

Insulin

Excess Weight Loss is ~65-70%*

(39)

Duodenal Switch

• Combination operation

•

Sleeve

•

Biliopancreatic Diversion

•

Neurohormonal – decreased

Ghrelin and increased GLP1

• Highest remission rate for

type 2 diabetes

• ~85% Excess Weight Loss

(40)

Nutritional and Metabolic Deficiencies

After Bariatric Surgery

13

•

Gastric restrictive procedures

• Iron deficiency 32%

• Thiamine deficiency

•

Roux-en Y gastric bypass

• Calcium (50% to 60%) and vitamin D (20% to 60%)

• Iron deficiency 15% to 50% (49% to 52% with BMI >50)

• Decreased acidification and proximal small bowel absorption

• B12 deficiency 10% to 70% 1 to 9 years after* (half-life 400 d) • Decreased liberation of B₁₂ from protein foods

• Decreased intrinsic factor production • Decreased ileal absorption

• Requirement = 2 mcg/day; stores = 3000 to 5000 mcg

• Thiamin deficiency

• Folic acid deficiency 10% to 35% due to low intake and ↓ gastric acid

• Protein deficiency (<1% to 4.7%)1

(41)

Routine Vitamin and Mineral

Supplementation for RYGB Patients

RYGB = Roux-en-Y gastric bypass.

14

Supplement Dosage

Multivitamin 1 to 2 daily

Calcium citrate with vitamin D 1200 to 2000 mg/day + 3000 U/day vitamin D

Elemental iron 40 to 65 mg/day

Vitamin B12 5000 µg/day orally OR1000 µg/month IM OR

500 µg weekly intranasal

RYGB = Roux-en-Y gastric bypass

(42)

Bariatric Surgery - Low Mortality

0.13% 0.52% 0.93% 3.30% 0.0% 1.0% 2.0% 3.0% 4.0% 5.0%

Bariatric

Surgery

Lap Chole

Replacement

Hip

CABG

Mortality Rate (%)

When performed at a bariatric surgery center of excellence.

CABG = coronary artery bypass grafting; lap chole = laparoscopic cholecystectomy. Ballantyne GH, et al. Obes Surg. 2008;18(6):660-7.

ASMBS. Bariatric Surgery Misconceptions. http://asmbs.org/patients/bariatric-surgery-misconceptions.

0.13% mortality, n=5,365 bariatric surgery patients, 1998 and June 2006

Mortality %

.13%

0.52%

0.93%

(43)

Reduction of Premature Death

0.68% 6.17% 0.0% 2.0% 4.0% 6.0% 8.0% 10.0% Bariatric* Controls MO RTA LI TY

89% Reduction in Risk of Death Over 5 Years

* Includes perioperative (30-day) mortality of 0.4%.

P=.001

Christou NV, et al. Ann Surg. 2004;240(3):416-24.

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Gelesis100 Hydrogel in the Gastrointestinal Tract

Gelesis100 [package insert]. Boston, MA: Gelesis; 2019.

Particles degrade in the large intestine, water is released and

reabsorbed by body, and

remnants are eliminated from body

Particles maintain their structure and mechanical properties through

the small intestine Particles are released and expand

in stomach by absorbing water

3 Gelesis100 capsules administered

with water 20–30 minutes prior to

lunch or dinner

Particles mix homogenously with food to increase volume and elasticity of stomach contents,

(47)

Currently Available Treatments:

Risks and Efficacy

Lower risk

Higher risk

Lower efficacy Higher efficacy

BPD-DS Devices* Pharma Diets VLCD Lap band Sleeve Roux-en-Y bypass .

Jensen MD, Ryan DH, et al. J Am Coll Cardiol. 2013;pii:S0735-1097(13)06030-0. http://formularyjournal.modernmedicine.com/print/368664. Accessed May 12, 2014.

*Gastric sleeve and vagal stimulator under phase 3 study SVLCD: very low calorie diet

(48)

Final Thoughts…….

•

Diet and Exercise remains the cornerstone – Even with surgery

•

Continuum of care

• Pharmacotherapy • Devices

• Bariatric surgery

•

“GPS MODEL OF CARE”

•

Work with your provider to side best option(s) for you!

•