Obesity: Striving Towards Long-Term Weight Loss

Dr. Buch:
Obesity is a worldwide phenomenon and the association between obesity, morbidity, and mortality is well known. We all want our obese patients to be successful in their weight loss, but how do we achieve this long term?

This is GI Insights on ReachMD, I'm Dr. Peter Buch. Joining me today is Dr. Devika Umashanker, Obesity Medicine Director of the Department of Bariatric Surgery at Hartford HealthCare Medical Group. Dr. Umashanker, thanks so very much for being here today.

Dr. Umashanker:
Thank you for inviting me, Dr. Buch. 

Dr. Buch:
So, let's get right into the discussion. Dr. Umashanker, would you discuss how the patient's BMI and comorbidities guide us towards appropriate treatment?

Dr. Umashanker:
Sure, absolutely. So, in terms of treatment, we really utilize the BMI scale to tailor what type of treatment plan would be appropriate for our patients. What we know in terms of elevated BMI, there is a high correlation for the number of comorbidities one may have, for example, higher BMIs have showed elevated blood pressure, elevated sugar association, elevated cholesterol association. So, what we have done as an obesity medicine community is to see how we can tailor programs to our patients appropriate for their BMI. For example the diagram that we always utilize is looking at people's BMI after the BMI of 27. Usually a BMI of 25-27 allows for nutritional recommendations, lifestyle modifications, and that's where we utilize our nutritionists and our psychologists, and even our exercise physiologists to really help develop a treatment plan appropriate for our patients. What we do know is patients with a BMI of 27 with one weight-related comorbidity are eligible for medications. And then anyone with a BMI greater than 30 could be eligible for medications. We also utilize above that BMI reference range as well. So, BMI greater than 35 with a weight-related comorbidity, we have seen bariatric surgery to be quite successful. That criteria can even extend for a BMI greater than 40 without a weight-related comorbidity, where one would be eligible for surgical weight loss. Which treatment plan one chooses, I would recommend them to speak to their primary care physician or an obesity medicine specialist that is within their area to really discuss the details of that plan and what may be appropriate for our patients in terms of their lifestyle, their expectations, and how we can make them to be more successful in the treatment plan we devise with them.

Dr. Buch:
That's great. All clinicians have difficulty having patients adhere to their diets long-term. Do you have any pearls to share with us?

Dr. Umashanker:
Yes. So, I think adherence is a very big challenge for all of us. Especially dietary adherence. So, what I think is very effective and helpful is for my patients to pick a diet that works for them. There was actually a study that was done several years ago that looked at different diets. They looked at Weight Watchers, they looked at Ozone, and other diets to see which diet would someone respond the best to. And what they noted was there wasn't specific diet that is the prescription for everyone, but rather tailoring a diet to a patient's dietary preference really seems to be very successful. So, in our program we try to individualize the diet for our patients. But what I wanted to add to that is only one element. What has been studied is the Mediterranean plan, and what we notice is that plan has shown to have higher adherence rate. So, in some of our programs, we actually provide a Mediterranean plan for our patients and they work with our nutritionists to tailor that Mediterranean plan to their preference. Another element that I find to be very successful, but some of my patients may need a little coaching on that, is self-monitoring of your food intake. Many studies have shown that to be very successful in allowing patients to recognize what they're eating and being adherent to their diet that's been proposed by their physician. It takes time, but I think those that have implemented that into their new program find it to be quite successful and they can see that with their weight going down.

Dr. Buch:
Thank you. What I found particularly helpful, Dr. Umashanker, is some sort of a reminder or encouragement for the patients on a regular basis, either a phone call or a message. Could you comment about that?

Dr. Umashanker:
Yes, absolutely. So, I think having multiple contact points in a weight loss program is not only helpful in encouraging patients, checking in on them, but also helps them to keep accountable. I know there has been studies that looked at lifestyle interventions and one of the studies showed that having 13 points of contact in one year has shown to be very helpful in keeping patients accountable and adhering to that diet. So, absolutely, having reminders, having the program call the patient biweekly or bimonthly to see how they're doing, I think is very very important and helpful.

Dr. Buch:
Our next question is prescription drugs are often a source of weight gain. Could you share some examples and outline alternative therapies?

Dr. Umashanker:
Yes, absolutely. So, in our program when someone comes we definitely do a review of medications to see what can be weight-promoting. One of the more common medications that we see is insulin. Insulin is a medication that is utilized for the treatment of diabetes. Our recommendation is not to completely take off insulin, because obviously it needs to be monitored along with your A1c value, but to maybe utilize alternative therapy in combination with the insulin such as GLP-1 analogs that have shown to be very helpful with weight loss and potentially doing a cross-titration between the insulin and GLP-1 alanog. That's very common. We recognize medications that are antipsychotics can be weight-promoting, or even mood-stabilizers, or antidepressants. So, that's where it gets a little bit tricky. I believe it's really challenging to get the right combination in terms of psychiatric medications to make your patients feel well. So I necessarily don't utilize alternative therapy, I work very closely with our psychiatric colleagues and potentially add other medicines that work more metabolically that may not interfere with those medications' mechanism of action. Some medications that we may not even recognize, our patients may not even be aware of, that many times can be weight-promoting was cetirizine. Trazodone is another medication that can be weight-promoting utilized as a sleep enhancement. So for trazodone, one of my recommendations is that we do utilize medications like Topiramate that can be sleep-enhancing as well as weight-loss-promoting. With cetirizine I use loratadine as an alternative therapy so we can avoid weight-promoting medications. So, those are some of the more common medications I see with my patients that I try to utilize alternative medications or add medicines that can at least neutralize the weight gain.

Dr. Buch:
For those just joining us, this is GI Insights on ReachMD, I'm Dr. Peter Buch, and today I'm speaking with Dr. Devika Umashanker about obesity. So, Dr. Umashanker, could you outline the pros and cons of using anti-obesity medications?

Dr. Umashanker:
Yes.  I always find anti-obesity medications as a great alternative so patients who are not ready for surgical weight loss, may not qualify for surgical weight loss, or just have a very medically-complicated history and can't pursue that pathway. The pros of utilizing anti-obesity medications is really looking at weight as a chronic disease and managing it as a chronic disease, very similar to type 2 diabetes, hypertension, dyslipidemia. But one of the cons of anti-obesity medication is that we do not have that many of them that are available that are FDA-approved. And even when they're available they are not covered by insurance. So, there are very limiting factors that we have to be able to utilize these medications for our patient population. And another challenge that I experience as a provider is that with many of our medications work in the brain pathway, and so, for our patients who may have a very complicated psychiatric history, we're not able to utilize these medications. I think in general with weight loss medications, anti-obesity medications, there is a stigma that's associated very appropriately because of the side effects previous medications has exhibited, but I can share with you that, you know, it's come a long way and, we have seen such an improvement in terms of patient's quality of life and health factors, that I encourage providers to utilize the anti-obesity medications as part of their management with their patient very similarly to the way we would utilize medication treatments for blood pressure or for cholesterol.

Dr. Buch:
So let's move on to bariatric surgery. How do you decide among adjustable gastric band, gastric bypass, and vertical sleeve gastrectomy?

Dr. Umashanker:
Yes great question. So, with bariatric surgery, there are different surgical options. I know in recent years many bariatric surgeons have shied away from the utilization of gastric banding due to many of the side effects patients have experienced - slippage prolapsing of stomach, and so, because of that, we don't use it so often or it's not really recommended. But in terms of sleeve gastrectomy and Roux-en-Y gastric bypass we've seen patients deciding to go with gastric bypass if, for example, they have a history of type 2 diabetes, uncontrolled diabetes, we have seen really great results with gastric bypass helping with alleviating hypoglycemic issues associated with type 2 diabetes. Also when individuals have Barrett's esophagus and they don't really qualify for sleeve gastrectomy, gastric bypass is another option. But more often than not sleeve gastrectomy is the most common procedure that's being presently done by our surgical providers.  I think it has a lot to do with the technique, the lower complication rate associated with it, the lower nutritional deficiencies that are associated with as well. But either-or, I think what usually happens is you have a really informed conversation with the patient outlining the pros and cons of each surgical procedure and make an informed decision process with the patient.

Dr. Buch:
What should we do when surgery is only partially successful?

Dr. Umashanker:
We see that all the time where patients don't really obtain that total-body weight loss that may have been shared with them that they potentially can obtain after surgery. And I think that's where it's really a nice energy about incorporating obesity medicine specialists into that program when patients are only partially successful. And by that I mean, after someone has a surgical procedure, have them see an obesity medicine specialist to make sure that this patient is achieving the goals that are supposed to occur in terms of their weight loss, and if it's not occurring speaking to the provider, understanding why is it not occurring? Is it because there's issues with the nutritional aspect of it, or is it a more physiological aspect of it? Because what we do know is, for example, patients that have obesity have a baseline level of low GLP-1, high ghrelin, and low leptin levels and sometimes we see when even after surgery, patients never have levels of satiety one would expect with this metabolic surgery. So, that's where it allows us as medicine providers who specialize in this to look at the whole chart and be able to prescribe medications to help augment their weight loss, at the same time alleviate any sort of challenges that they're having at that time.

Dr. Buch:
And lastly, what additional insights would you like to share with our audience today?

Dr. Umashanker:
So, you know, I have been an obesity medicine provider for over four years and what I want to share with you is that weight is very challenging and weight loss is very complicated. I feel that many of society has taught us that it's really environment that plays a role what you eat and a lack of exercise. And if there's one thing I hope people take away from what obesity medicine is, is that it is very different complex factors that plays a role, for example, genetics, epigenetics, environment, other medical factors that play a role, and so when a patient has not achieved the weight loss goal they're hoping to achieve, to really be able to work with them, understand all the challenges that come with weight loss, and really provide a program that they can be successful in.

Dr. Buch:
Well, that's all the time we have for today. I want to thank Dr. Devika Umashanker for joining me to discuss this very important topic. Dr. Umashanker, it was great speaking with you today.

Dr. Umashanker:
It was a pleasure being here, thank you.

Dr. Buch:
For ReachMD, I'm Dr. Peter Buch. To access this episode and others from GI Insights, visit ReachMD.com/GI Insights where you can Be Part of the Knowledge. Thanks for listening.