Tuesday, January 27, 2015

Canadian Clinical Practice Guidelines For Obesity: We Need More Than Diet and Exercise

sharma-obesity-doctor-kidYesterday, saw the release of new Clinical Practice Guidelines from the Canadian Task Force on Preventive Health Care to help prevent and manage obesity in adult patients in primary care.

Similarly to the Endocrine Society’s Guidelines for the pharmacological treatment of obesity (see yesterday’s post), the authors use a GRADE system to rank and rate their recommendations.

Key recommendations are summarized as follows:

  • Body mass index should be calculated at primary health care visits to help prevent and manage obesity.
  • For normal weight adults, primary care practitioners should not offer formal structured programs to prevent weight gain.
  • For overweight and obese adults health care practitioners should offer structured programs to change behaviour to help with weight loss, especially to those at high risk of diabetes.
  • Medications should not routinely be offered to help people lose weight.

Virtually all of these recommendations are supported by evidence that is rated between moderate to very low, which essentially leaves wide room for practitioners to either do nothing or whatever they feel is appropriate for a given patient.

The guidelines do not discuss the role of bariatric surgery (arguably the most effective treatment for severe obesity) and make no recommendations for when this should be discussed with patients.

The rather subdued recommendations for the use of medications is understandable, given that the only prescription medication available for obesity in Canada is orlistat (why the authors chose to also discuss metformin, which is not indicated for obesity treatment, is anyone’s guess).

Overall, the reader could easily come away from these guidelines with a sense that obesity management in primary care is rather hopeless, given that behavioural interventions are modestly effective at best (which is probably why the authors recommend that these not be routinely offered to patients at risk of weight gain).

Indeed, it is hard to see how primary care practitioners can get more enthusiastic about obesity management given this rather limited range of treatment options currently available to Canadians.

If there is anything to take away from these guidelines, it is probably the simple fact that we desperately need more effective treatments for Canadians living with obesity.

@DrSharma
Edmonton, AB

The whole document is available here

VN:F [1.9.22_1171]
Rating: 10.0/10 (2 votes cast)
VN:F [1.9.22_1171]
Rating: +2 (from 2 votes)


Monday, January 26, 2015

Endocrine Society Clinical Practice Guidelines For The Pharmacological Treatment of Obesity

sharma-obesity-medications6Last week, the US Endocrine Society released a rather comprehensive set of evidence-based clinical practice guidelines for the pharmacological management of obesity, published in the Journal of Clinical Endocrinology and Metabolism.

The recommendations in the 21-page document follow the rather rigorous Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) group (from 0 to 4 stars) and goes beyond just evaluating the evidence in favour of pharmacological treatment of obesity itself but also for the pharmacological treatment of overweight and obese individuals presenting other medical conditions.

Here are the (in my opinion) most important recommendations from this document:

1) While diet, exercise and behavioural interventions are recommended in all patients with obesity,

“Drugs may amplify adherence to behavior change and may improve physical functioning such that increased physical activity is easier in those who cannot exercise initially. Patients who have a history of being unable to successfully lose and maintain weight and who meet label indications are candidates for weight loss medications.(****)”

2) “If a patient’s response to a weight loss medication is deemed effective (weight loss > 5% of body weight at 3 mo) and safe, we recommend that the medication be continued. If deemed ineffective (weight loss < 5% at 3 mo) or if there are safety or tolerability issues at any time, we recommend that the medication be discontinued and alternative medications or referral for alternative treatment approaches be considered. (****)”

3) “If medication for chronic obesity management is prescribed as adjunctive therapy to comprehensive life- style intervention, we suggest initiating therapy with dose escalation based on efficacy and tolerability to the recommended dose and not exceeding the upper approved dose boundaries. (**)”

The guidelines also make specific recommendations for the pharmacological treatment of overweight and obese individuals presenting with a wide range of other medical issues, including 2 diabetes mellitus (T2DM), cardiovascular disease, psychiatric illness, epilepsy, rheumatoid arthritis, COPD, HIV/AIDS and allergies.

For example:

“In patients with T2DM who are overweight or obese, we suggest the use of antidiabetic medications that have additional actions to promote weight loss (such as glucagon-like peptide-1 [GLP-1] analogs or sodium-glu- cose-linked transporter-2 [SGLT-2] inhibitors), in addi- tion to the first-line agent for T2DM and obesity, metformin. (***)”

The guidelines also discuss the pros and cons of the anti-obesity medications currently available in the US (phentermine, orlistat, phentermine/topiramate, lorcaserin, buproprion/naltrexone, and liraglutide), which we can only hope will soon also become available to patients outside the US.

The entire document is available here.

@DrSharma
Edmonton, AB

VN:F [1.9.22_1171]
Rating: 8.7/10 (3 votes cast)
VN:F [1.9.22_1171]
Rating: +2 (from 2 votes)


Friday, January 23, 2015

GLP-1 Analogue Liraglutide For Obesity Gets Positive Vote In Europe

novo_nordiskJust one month after the GLP-1 analogue liraglutide 3 mg received approval for obesity treatment by the US-FDA, liraglutide 3 mg, yesterday, also got a positive nod from the Committee for Medicinal Products for Human Use (CHMP) under the European Medicines Agency (EMA).

Here is how the Novo Nordisk press release describes the mode of action and indication for liraglutide 3 mg:

Saxenda®, the intended brand name of liraglutide 3 mg, is a once-daily glucagon-like peptide-1 (GLP-1) analogue, with 97% homology to naturally occurring human GLP-1, a hormone involved in appetite regulation. The CHMP positive opinion recommends that Saxenda® will be indicated as an adjunct to a reduced-calorie diet and increased physical activity for weight management in adult patients with an initial Body Mass Index (BMI) of >=30 kg/m2 (obese), or >= 27 kg/m² to < 30 kg/m² (overweight) in the presence of at least one weight-related comorbidity such as dysglycaemia (pre-diabetes or type 2 diabetes mellitus), hypertension, dyslipidaemia or obstructive sleep apnoea.”

Regular readers will be aware of the role that the incretin GLP-1 plays in the  regulation of glucose metabolism as well as satiety and appetite.

Data for this approval come from the Phase 3 SCALE trial program involving over 5,000 patients with overweight and obesity, the majority of who also had related comorbidities.

Given that this is an injectable drug that will be available only with a  doctor’s prescription and, as any anti-obesity medication, will need to be used in the long-term, it will be interesting to see how this new approach to obesity treatment will be accepted by doctors and their patients.

Although liraglutide 3 mg may not work for or be tolerated by everyone, I am confident that this much-needed addition to the obesity treatment tool-box will provide a new treatment option to some patients – especially those with obesity related health problems.

@DrSharma
Edmonton, AB

Disclaimer: I have received honoraria for consulting and speaking from Novo Nordisk

VN:F [1.9.22_1171]
Rating: 0.0/10 (0 votes cast)
VN:F [1.9.22_1171]
Rating: 0 (from 0 votes)


Thursday, January 15, 2015

FDA Approves VBLOC Treatment For Obesity

enteromedicslogowithtechlarge3x2We don’t have great treatments for obesity, so every new evidence-based tool in the obesity treatment tool box is something to look at closely.

The latest addition, just approved by the US FDA for the treatment of obesity  in adults with a BMI of 40 to 45 kg/m2 or a BMI of 35 to 39.9 kg/m2 with a related health condition, is something I’ve posted about before - VBLOC or the vagal “pacemaker” as it is sometimes referred to.

Indeed, Enteromedics‘ rechargeable Maestro system is very much like an implantable cardiac pacemaker, in that it delivers an electronic signal – in this case to block the action of the vagus nerve. The exact mode of action is not entirely clear but the weight-loss mediating effect (in the 10-15% average range) is largely a result of reduced appetite and increased satiety.

Here is how Enteromedics describes its system:

The Maestro® System consists of a subcutaneously implanted rechargeable neuroregulator and two electrodes that are laparoscopically implanted by a bariatric surgeon. It delivers VBLOC® vagal blocking therapy via these electrodes that are placed in contact with the trunks of the vagus nerves just above the junction between the esophagus and the stomach. The device intermittently blocks vagal nerve signals throughout the patient’s waking hours. The Maestro System is recharged using an external mobile charger and transmit coil worn by the patient. The device can be non-invasively programmed, and it can be adjusted, deactivated, reactivated or completely removed if desired.”

Obviously this is far from the be-all and end-all of obesity treatments – especially as it does not seem to work for everyone. Thus, the recently published results from the pivotal study (discussed here),  was certainly far less impressive than the company may have hoped for.

Just where VBLOC treatment will ultimately find its place in bariatric care remains to be seen – this is certainly a space to watch.

@Dr. Sharma
Edmonton, AB

 

VN:F [1.9.22_1171]
Rating: 10.0/10 (1 vote cast)
VN:F [1.9.22_1171]
Rating: +1 (from 1 vote)


Wednesday, January 14, 2015

Guest Post: Bariatric Foodie

Nikki Massie, Bariatric Foodie

Nikki Massie, Bariatric Foodie

Last year, at the Obesity Action Coalition’s annual conference, I met Nikki Massie, who underwent Roux-en-Y gastric bypass surgery seven years ago and writes a blog with recipes and other advice for people post bariatric surgery (“Bariatric Foodie“).

As I am always eager to hear the perspective of someone living with bariatric surgery, I invited Nikki to send me a guest post – here it is:

My name is Nikki Massie and seven years ago I underwent Roux-en-Y gastric bypass surgery in Baltimore, Md.

Last year I wrote an article on my journey in the National Inquiry of Bioethics and in it I described having weight loss surgery as, “stepping off the edge of the earth and trusting there’d be a soft place to land.” I had been overweight my entire life. I was over 9 lbs. at birth and trended above the top of the growth charts throughout my childhood.

The decision to have surgery came by way of motherhood. I was 31 years old and I had two daughters, aged 8 and 6. One day, watching them play at the playground I realized that if I didn’t do something soon, I would probably miss many moments in their lives due to lack of energy and the myriad health problems associated with obesity. At the time I was 340 lbs.

In January 2008, I had my surgery.

That was the start of my journey, and it’s where I’d like to start with a few things I’d like you to know from the patient perspective.

All the tests in the world can’t predict how a patient will react emotionally. I realized shortly after my surgery that I am a food addict. Restriction plunged me into a deep depression and anxiety. Some days the only way I knew how to cope was wandering supermarket aisles looking at food. Thankfully I found a great resource in Overeaters Anonymous and I’m working on my own recovery.

Bottom Line: Stress to your patients the importance of having mental health support. Encourage them to find a therapist, come to support group or utilize any other mental health tools at their disposal.

Weight and self-image vary from culture to culture. I think that’s important to note because within my own African-American culture, being a curvy woman is not stigmatized, but often celebrated. Being “skinny” is not necessarily a cultural value. I hear from many African-American women post-ops that they worry they will get too small and they work against losing past a certain amount. There is also familial and community pressure share in traditional foods and to look a certain way.

Bottom Line: It helps to ask about traditions and culture and how food plays into them and then help them find a healthier alternative!

In the long-term many post-ops feel abandoned. In a blog series I wrote for Obesity Action Coalition, I noted that many long-term post-ops felt alienated at their support groups. Many shared the feeling that they seemed more geared toward newer post-ops than long-termers. In addition, many weren’t sure what follow-up they needed after the two-year post-op mark.

Bottom Line: Does your office see patient’s long-term? If so, reach out to them and get them into the office. If not, make sure your patients know how to talk to their primary care physician about any issues that might arise and also make them aware of the existence of bariatricians!

The Bottom Line For Me

I recently celebrated the seven-year anniversary of my surgery. I’ve regained about 30 lbs. I continue many of the lifestyle habits I adopted: I go to the gym several times a week, I follow a high protein eating plan, but most of all I have more energy and I am in good health, even though I have regained.

These days I stay connected via my website, Bariatric Foodie, which encourages readers to reimagine their favorite foods in a healthier way, but also challenges them to make goals, practice accountability and think realistically and critically about their weight loss process.

If you have any questions I’m happy to answer them in the comments or via email at bariatricfoodie@yahoo.com

VN:F [1.9.22_1171]
Rating: 8.6/10 (13 votes cast)
VN:F [1.9.22_1171]
Rating: +4 (from 4 votes)

In The News

Diabetics in most need of bariatric surgery, university study finds

Oct. 18, 2013 – Ottawa Citizen: "Encouraging more men to consider bariatric surgery is also important, since it's the best treatment and can stop diabetic patients from needing insulin, said Dr. Arya Sharma, chair in obesity research and management at the University of Alberta." Read article

» More news articles...

Publications

  • Subscribe via Email

    Enter your email address:

    Delivered by FeedBurner




  • Arya Mitra Sharma
  • Disclaimer

    Postings on this blog represent the personal views of Dr. Arya M. Sharma. They are not representative of or endorsed by Alberta Health Services or the Weight Wise Program.
  • Archives

     

  • RSS Weighty Matters

  • Click for related posts

  • Disclaimer

    Medical information and privacy
    Any medical discussion on this page is intended to be of a general nature only. This page is not designed to give specific medical advice. If you have a medical problem you should consult your own physician for advice specific to your own situation.


  • Meta

  • Obesity Links

  • If you have benefitted from the information on this site, please take a minute to donate to its maintenance.

  • Home | News | KOL | Media | Publications | Trainees | About
    Copyright 2008–2015 Dr. Arya Sharma, All rights reserved.
    Blog Widget by LinkWithin