Dr. Wardrop: thank you all for being here. Anthony, you came to us with this topic for the podcast based on your work with Dr. Simon-Linares in this area. Knowing you, I know you have some questions in mind to start us off, and you wanted to lead into these with a case, so please take it away.
Anthony: Let’s use a fictional case to improve our learning
Case: This is a 57-year-old female with relevant PMH including Obesity Class III, osteoarthritis, Type II Diabetes Mellitus, Hypertension, and hyperlipidemia. She presents for evaluation of weight management in the Bariatric Endoscopy Clinic. Presently she weighs 284 lbs. and has a BMI of 44. Her weight at age 18 was approximately 200 lbs. With lifestyle modifications she was able to reduce her weight to 260 lbs. However, 8 months ago she was in a motor vehicle accident where she broke her arm and injured her back; as a result, she regained lost weight and is now at her present weight of 284 lbs.
She works a predominantly sedentary desk job. Her 24-hour dietary recall includes appropriate caloric and nutritional intake during the day however 2-3 nightly awakenings per week to eat. The patient also reports she could eat several high caloric meals and beverages per day despite not feeling very hungry. She also states that she does not feel full after eating several meals.
Her relevant medications include insulin glargine 30 units nightly, metformin extended release 500mg BID, empagliflozin 10mg daily, and semaglutide 1.0mg daily,
Dr. Wardrop: So, our first question is for Roberto.....Please define obesity
Dr. Simons-Linares: Complex medical disease not just a cosmetic disease. We must have a shift in our medical focus to recognize obesity as a disease, just as we recognize diabetes or hypertension diseases with nuances.
Diagnostically, defined by BMI into Class I, II, or III where BMI is used to stratify 30-34.9; 35-39.9; 40+.
Arjun: There are many treatment options available for obesity. When I see patients, I counsel them on the importance of lifestyle modifications. Often, patients hear about many medications in the media and their sensational claims associated with weight loss and come to me asking about prescribing these medications. Can you describe how much expected weight loss someone would have with lifestyle modifications and with some common anti-obesity medications?
Dr. Simons-Linares: Lifestyle modifications: LookAHEAD Trial with intensive coaching, scheduled exercise, dietician, psychology – in 10 years trial was prematurely stopped. Patients only lost 6% and it did not improve cardiovascular risk factors or cardiovascular mortality.
Anthony: At this point, the patient is not interested in endoscopic therapy or bariatric surgery. What evidence-based steps would we take at her first clinic visit to give her the best chance for an optimal outcome in her weight loss journey?
Dr. Simons-Linares: Identify her subtype of obesity (hungry brain, hungry gut, metabolic predominant, mixed type)
Based on her information, she would benefit from an uptitration of her semaglutide as well as the addition of topiramate 25mg nightly to curb the feelings of nocturnal eating. Meet with Bariatric Psychologist & Bariatric Dietician.
Arjun: Erika, as a bariatric psychologist, what does that first meeting with a patient look like? What are some key discussion points or information that you use to help patients?
Erika: I use the first visit to emphasize the chronic disease model of obesity as well as the emphasize the nature of our program as being a “medical home” model of care. Meaning, we will continue to support the patient for chronic disease management across the lifespan- knowing that weight gain is something we have to accept about the disease itself. The rest of the visit is a pretty thorough interview covering a broad range of the individual's experience. I like to describe it to patients as “looking at the places stress tends to hide” because ultimately, we need a broad picture of how the patient has built habits as the solutions to other problems they have experienced in various areas of life. By the end of the first visit, I can share with the patient some opportunities to fill in the gaps- either with resources, education, or things we want to monitor to prepare for any kind of procedure.
With regards to the case you shared, this patient’s nocturnal eating will limit her goals for weight loss. Sometimes, patients have relief from medications to treat this pattern and in other cases they need support in improving sleep hygiene, distress tolerance, and self-observations skills to make sustainable changes. Similarly, the incident of injury or illness is something that can often catch us off guard- and unfortunately can be a common contributing factor to weight gain. I would want to be involved in the patients care for supporting how they adjust to these types of changes (aka stressors).
Anthony: Bailey, how do you help patients in their weight loss journey? It may seem obvious in conversation, but why should patients see a dietitian in their weight loss process?
Bailey: There is so much nutrition and diet information out there nowadays with more social media use and the increasing prevalence of obesity worldwide. So for patients with obesity, it is crucial for them to receive medically appropriate nutrition advice for their treatment and as registered dietitians we are trained to use evidence-based research and guidelines to do this. Our goal for any patient working with myself or any dietitian in our program is to work with them to establish a strong nutrition foundation and habits that are going to aid in their treatment with endoscopic therapies in combination with other lifestyle modifications. Nutrition is not a one size fits all, so it is important to work with our patients to form these lifelong nutrition habits that meet our recommendations but at the same time fit into their needs and life as well.
Anthony: The patient trials both of these things and returns to see Dr. Simons-Linares in 3 months. She now weighs 260 lbs. which represents a 7% total body weight loss during that time. After thinking about it, she now is interested in learning about endoscopic approaches for weight loss. What is bariatric endoscopy and how does it differ from other bariatric procedures? What is the role of bariatric endoscopy in treating obesity?
Dr. Simons-Linares: Phenotypes are hungry brain, hungry gut. Procedures can be Endoscopic sleeve gastroplasty; intragastric balloon.
Anthony: The patient ultimately elects to proceed with endoscopic surgery. The procedure goes well, and her recovery is uneventful. What does her post-procedural life look like? Does she stop all anti-obesity medications? Should she follow-up with the bariatric endoscopy team?
Dr. Simons-Linares: Continue medications, continue follow-up, may need surgical intervention
Dr. Wardrop: To our team, thank you so much for your wonderful discussion Before we go, can you give the listeners especially those in training and those in primary care, some key summary take-home points from today’s episode?
