Bariatric Times

Insights into Patient Pop with Obesity 2016

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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C10 Bariatric Times • December 2016 • Supplement C predisposing patients to fat storage, and elevating their risk of comorbid conditions such as diabetes. 21 Once the basic ILI plan is crafted, the patient can use this to begin the treatment. For some patients, however, this level of intervention is insufficient, and the next layer must be added. IlI + ANTI-OBeSITy MeDICATIONS Anti-obesity medications (AOM) when added to ILI represent the second domain for obesity treatment. AOM should be used after ILI and before intermediate procedures. AOM should be considered in patients with a BMI >30kg/m 2 or in those with a BMI >27kg/m 2 with comorbid conditions. Before selecting pharmacotherapeutic options, the prescriber should consider how well the patient did using just ILI alone, how much weight was lost, and how quickly it was lost. There are a number of AOM available with unique mechanisms of action. 22 Prescribing choices should be guided first by understanding contraindications of AOMs and then by understanding the patient's symptoms, such as overriding persistent hunger, specific or very strong food cravings, or a tendency toward emotional eating. In some cases, AOMs may help address the patient's comorbidities or provide additional benefits. Patient monitoring over the course of therapy can help confirm whether or not the prescribed AOM is effective and if the patient is experiencing side effects or tolerability issues. By monitoring at around three months, it should be possible to determine if reasonable weight loss goals have been met and if the patient is tolerating the medicine well. It may benefit the patient to escalate from ILI alone to ILI plus AOM sooner in the patient's continuum of care rather than later. With a large and robust armamentarium of AOMs, there are more options for early intervention. In many primary care clinics, escalation to AOMs may happen only slowly, if at all. It may be erroneously believed that AOMs should only be considered for the most extreme cases of obesity. In fact, AOM treatment is prescribed to only about one percent of patients with obesity, which indicates many patients who would benefit from it are not receiving it. 22 IlI + INTerMeDIATe PrOCeDureS The third domain adds another layer: intermediate procedures such as gastric balloons, gastric emptying systems, or an electrical stimulation system. These are not considered surgical procedures, but rather represent temporary devices intended to be used for a specific but not indefinite period of time. These procedures should always supplement an underlying ILI foundational program and often with AOM pharmacotherapy. There are many considerations with this domain including tolerability issues (not all patients can tolerate these systems) and efficacy. 23 Gastric Baloon. Gastric balloon systems are appropriate for patients with a BMI ≥ 30kg/m 2 . The gastric balloon is placed in the patient endoscopically although in the future, it may be possible for the patient to simply swallow the balloon. It occupies space within the stomach which stimulates the hormones that provide the patient with the sensation of fullness and satiety. 24,25 Gastric emptying System. A gastric emptying system is appropriate for patients over age 22 with a BMI in the range of 35 to 55kg/m 2 . This system requires surgical placement that uses an internal tubing system, a port or valve in the skin, and an external pump to remove substances out of the stomach. 26 The device is activated by the patient, who affixes a tube to the port to empty the stomach. To be effective, the system must be used within 30 minutes of taking in a meal. The gastric emptying system can remove about 30 percent of the caloric content of the meal. electrical Stimulation System. An electrical stimulation system should be used in patients either with a BMI in the range of 35 to 39kg/m 2 with one comorbid condition or a BMI ≥ 40kg/m 2 . The concept of an electrical stimulation system is that nerve activation can blunt signals of hunger and encourage signals of satiety. 27 Insights into the Patient Population with Obesity: Assessment and Treatment

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