Failing that, failing diet and beyond exercise,
of course, those are always going to be foundational.
We’re going to recommend those throughout.
There are four new medication introduced in the United States
for the treatment of obesity.
And they do work.
In clinical trials, more than half of
individuals treated with these medications
lost at least 5% of their body weight.
So, again, these are significant weight loss.
We’re talking along the lines of 6 kg, 8 kg, 9 kg.
Phentermine topiramate generally
has been associated with
the largest amounts of weight
loss in these clinical trials.
It appears to be safe right now.
All these drugs are being monitored
for their safety profile over time,
given the history of weight loss drugs,
but it does appear to be safe to take.
One thing with taking any drug with
topiramate in it is it can make
patients feel a little bit hazy or foggy,
with some difficulty in concentration.
So, that's one thing to watch and can
be managed by cutting the dose.
Liraglutide is a glucagon-like peptide-1 antagonist
and that drug is used to treat diabetes,
but it's also associated with weight loss.
It doesn't promote low sugar.
So, therefore, that's not a worry.
And it can be effective.
The main side effects with liraglutide
are gastrointestinal upset.
So that's something.
But, usually, if patients can make it through
the first week or two of treatment
and tolerate the drug okay
and see-through a little bit of nausea,
they’re going to be fine in taking over the long-term.
Naltrexone bupropion also is effective,
another combination agent.
Bupropion, we have to watch out for its effects
in patients with seizures because
it lowers the seizure threshold,
can have some effects on sleep as well,
but generally pretty well tolerated.
But say the patient is failing their diet,
and still has some indications for bariatric surgery,
that's the time to think about maybe
doing surgery for these patients.
So, bariatric surgery, the general indications,
the things you should know for the exam,
body mass index of 40 kg/m² or more
or at least 35 kg/m²
with complications of obesity,
primarily hypertension, diabetes.
Now, these treatments really do work.
It's possible to lose 50% of the body weight or more.
So, the improvements can be dramatic.
It's really the only thing that
cures diabetes, for example.
And one thing we do understand is
that now gastric volume procedures,
either the Roux-en-Y gastric bypass or
the gastric sleeve have become more
popular than the banding
procedure or laparoscopic band
because those procedures,
the gastric volume procedures
definitely promote greater weight loss.
So, if you want to lose a few pounds,
the band procedures are okay.
But if you really want to make a difference in
disease outcomes, like hypertension and diabetes,
gastric volume procedures
are definitely more effective.
And now the gastric sleeve is the most popular
form of bariatric surgery in the United States.
As I mentioned, it can be highly effective
in reducing the risk of diabetes,
it can reduce the risk of incident hypertension
and it also greatly improves pre-existing
diabetes and hypertension as well.
It’s associated – there is an associated
risk of complications.
3 to 5% of these gastric volume procedures,
whether we’re talking about the Roux-en-Y bypass
or the other sleeve can have leaks after surgery.
There is about a 1% perioperative
risk of serious adverse events,
which isn’t different than some other
procedures like an open cholecystectomy,
but still something to consider as
patients elect to have these procedures.
However, in the long term,
and particularly as patients get good counseling
and good follow-up,
so they understand what the procedure entails
and what their life will be like after the
procedure in terms of early satiety
and having to be evaluated for potential nutritional deficiencies
and having to titrate their diet accordingly,
those patients I think who are prepped
appropriately and followed appropriately
have a lifestyle that’s actually
improved after surgery versus not.
And I can say from personal experience,
those patients who have unreasonable expectations
and don't get the kinds of follow-up that they need
have oftentimes more side effects,
more symptoms and a worse lifestyle afterwards.
So, we discussed the epidemiology of obesity.
Diet and exercise are the cornerstone.
Really try to focus on those lower carbohydrate diets.
Those seem to be the ones that work best.
And you can work to that goal gradually
with the patients’ values in mind.
It is perfectly reasonable.
Medications can certainly help and they might
stimulate patients to lose a little bit more weight.
How long you continue those drugs
is a matter of controversy.
And for patients who fail diet
and exercise conservative therapy
and really are suffering with
obesity and its complications,
bariatric surgery is an option.
Hope you found that helpful.
Thanks very much for your attention.