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Role of Private Bariatric Medical Centres
ARE WE READY?Dr. Sean Wharton, MD, FRCPC
Internal MedicineWharton Medical Clinic
Adjunct Professor – York UniversityLead Author – Obesity Section - CDA Guidelines
CABPS, June 2012
Disclosures Grants/support
CIHR Heart and Stroke Foundation MITACS – Research
Honoraria/Advisory Board Novo-Nordisk Merck Bristol Myers Squibb Abbott Pharmaceuticals Eli-Lilly AstraZeneca
Objectives
Discuss the current environment of community based bariatric medicine
Example of a publically funded community based weight management clinic.
Current Environmentof Medical Bariatric
Centres Tertiary
HGH Ottawa Civic Edmonton Capital Region – Weight Wise
Community Practices Commercial
Weight Watchers Bernstein’s Herbal Magic
Evidence Based Practices BMI (Bariatric Medical Institute) Wharton Medical Clinic Family Medicine Practices
Yoni Freedhoff, MD
Questions?Community Based Bariatric
Programs Standardization
Funding
Meal Replacements Programs, Partial
Family Doctors or Specialists
Team Dietitians, nutritionists (bariatric educators),
exercise specialists, behavioural therapist, pharmacist, social work etc.
AnswersCommunity Bariatric
Medicine Efficient System – demand is great
Multi-disciplinary
Cost-effective
Family/childhood obesity a priority
115 Programs Analyzed
31 Surgical Programs2 Surgical Assessment Centres
82 Non-surgical Programs32 Community-based (group session, gym)41 Primary Health Care (MD, nurse, dietitian)7 Hospital-based
115 Programs
ASPQ Criteria for Bariatric Programs
Rate of weight loss Multi-disciplinary Dietary intervention (without long
term use of VLCD) Physical activity Effectiveness Safety Approach to advertising Cost Effectiveness
Pharmacotherapy 3/31 – surgical programs 12/82 – non-surgical program (11 PC, 1
hosp)
BMI Criteria 32/82 nonsurgical programs did not use
BMI as entry criteria
Primary care based programs show the greatest compliance. Encouraging – most accessible
Access to hospital-based non-surgical programs is extremely limited.
Bariatric surgery facilites are lacking in psychological supports, and physical activity compared to non-surgical programs.
Long-term weight-loss maintenance: a meta-analysis of US studies
13 Studies (VLCD and HBD) 1081 pts - F/U – 4.5 years Initial weight loss 30.8 lbs (14%)
Weight-loss maintenance 6.6 lbs (3%) 40.2% of patients maintained - 5% loss at 5
years NNT of 2.5
25% of patients maintained - 10% loss at 5 years
NNT of 5
Anderson et al. Am J Clin Nutr, 2001
Wadden et al. NEJM; Nov 14, 2011
Important aspects of a weight management clinic
Cost medical supervision frequent visits no pressure/non judgmental emotional support nutritional support convenient location with parking
How frequently would you like to come to a
professional centre for a weigh in?
34%
50%
2%
8%
4%
2%
every week
every 2 weeks
every 3 weeks
1/month
Whenever I want
no answer
Wharton Medical ClinicWeight Management Centre Launch – May 2008 A large community based bariatric
clinic – government funded – no charge to patients 9 Internists – 3 Nephrologist, 1
cardiologist, 2 ICU, 1 rheumatologist, 1 haematologist, 1 GIM
1 Dietitian/15 Nutritionist (Bariatric Educators)
Behavioural Therapy Team/Physiotherapy Team
Research Staff
Bariatric Educators
Education/Qualifications BSc Nutrition (Guelph, UWO, Ryerson) Post WMC - 2 MDs, 2 Masters, 4
dietitian internship Supervision/Quality Control
Dietitian/MDs 1/2 – 1/3 - salary of a dietitian Significant dietary concerns –
referred to the dietitian
WMC Clinic
Adults BMI 27-30 with 1 comorbidity, or
BMI>30 ? Change this to BMI 27 – 40 with 1
comorbidity, BMI > 40 (no comorbidities needed)
Treatment of cardio-metabolic conditions
Pharmacotherapy Surgical Referral/Medical and
Psychological Support/Pre and Post Op Management
Wharton Medical Clinic May 2012 19,069 pts (76% women)
3,734 pts current 75 - 100 new pts/week No waiting list 15-20 min GROUP education session at every
visit MD sees patient at every visit Visits q 1 – 3 weeks Metabolic and CV Risk assessment Evening Educational Classes Aggressive Diabetes Management
WMC Program Flowsheet
Visit #1BE/MD Visit
PMHX/Meds/Exam/Weight Hx/Consent to
research and Goals
Visit #2BE/MD Visit
Initiate Meal Plan
500 calorie/day deficit
Pedometer – walking
Resistance bands/Aqua
Organized eating
Visit q 3- 4 weeksBE/MD Visit
SUPPORT GROUPS
Manage medicallyDiabetic
managementCV management
Referrals
Baseline ECGBloodwork
RMRGXT
Wt, Ht, BMR, WC/HC
Blood pressure
WEEKLY WEIGH-INS ENCOURAGED – not billed to OHIP
1. FD - ASK
2. ASSESS
3. AGREE
4. ADVISE
5. ASSIST
BE #1Notes
BE #1Notes
BE #1Notes
Weight, Ht, BP, WC/HC
BE #1Notes
BE #2Presentations
BE #1Notes
BE #2Presentations
BE #3Individual visit
BE #4Individual visit
BE #5Individual visit
BE #1Notes
BE #2Presentations
BE #3Individual visit
BE #4Individual visit
BE #5Individual visit
BE #1Notes
BE #2Presentations
BE #3Individual visit
BE #4Individual visit
BE #5Individual visit
WMC - LecturesEducational Seminars
Topics How to complete a food journal Macro and micronutrients/label reading meal plans/eating out diabetic meal planning Emotional eating stress and weight, body image, support group Activity – pedometers, resistance bands
RMR Machine
Comparison of Group vs. Individual Treatment for Weight Loss: 6 months
0
2
4
6
8
10
12
14
16
Group Treatment
Preferred Non-Preferred
Individual Treatment
Preferred Non-Preferred
Wei
ght L
oss
(in
kg)
p < .02
Renjilian, Perri et al. J Consult Clin Psychol 2001; 69:717-721.
Barry at 404 lbs, BMI 60 Past Medical
History Diabetes Type 2 OSA – CPAP Hypertension High Cholesterol Urinary incontinence Hernia - ventral Obesity Class III Developmental Delay Intertrigo
Medications Metformin, Glyburide Ramipril, Lipitor
Barry’s Weight Loss Graph
Barry at 231lbs, BMI 33176lbs lost, 43% WL
Current Medical Hx OSA
CPAP turned down Diabetes type 2
Diet controlled Obesity Class I
Current Medications No medications
Off – metformin, ramipril, glyburide. Lipitor
Feasibility of a interdisciplinary
program for weight management in Canada
Sean Wharton MD; Sarah VanderLelie B.A.Sc; Saaqshi
Sharma M.Sc; Arya Sharma MD; Jennifer L. Kuk PhD
Canadian Family Physician, Feb 2012;852:32-8
Descriptive sample 1085 pts (3 months), 289 pts (6
months) 77% female
Age – 49.3 + 12.5 years
BMI – 40.5 + 8.1 kg/m2
69%
27% 21%
84%
33%45%
27%20%
0
500
1000
1500
2000
2500
Nu
mb
er
of
Pati
en
ts
Disease
Canadian Family Physician, Feb 2012;852:32-8
4743
38
3228
2117
1513986
0
10
20
30
40
50
1 2 3 4 5 6
Treatment Time (months)
Pre
vale
nce (
%)
5%
10%
Wharton et al. Can FamPhys, 2012;852:32-8
Prevalence of WMC Patients attaining
5% and 10% Weight Loss (18 months)
1,562 patients
Discontinuation (no visit in 3 months)
28.9% (N=452) lost 4.3 kg ± 6.1 3.7 % ± 5.0 of BW
31% - 5% weight loss 11% - 10% weight loss 8.4 ± 3.0 visits over 7.5 ± 1.4
months
Results- Prevalence of MNOB and MAOB
0%
10%
20%
30%
40%
50%
60%
70%
0 1 2 3 4 5 0 1 2 3 4 5
Baseline Follow-up
Prev
alen
ce (%
)
Clinical cutoffs Sub-clinical cutoffs
Number of metabolic risk factors
-7
-6
-5
-4
-3
-2
-1
0P
erc
en
t W
eig
ht
Lo
ss
(%
)
Sex
Ref
Female Male
Data adjusted for independent variables: sex, age group, BMI class, education, ethnicity and smoking status and treatment duration)
Unadjusted data
-7
-6
-5
-4
-3
-2
-1
0
Age Group
* Ref
Pe
rce
nt
We
igh
t L
os
s (
%)
**
*
Unadjusted Ptrend = 0.004
Adjusted Ptrend = 0.007
18-49 49-64 >64
-7
-6
-5
-4
-3
-2
-1
0W
eig
ht
Lo
st
(kg
)
BMI Category
Ref
* Unadjusted Ptrend <0.0001
Adjusted Ptrend <0.0001
OW OBCI OBCII OBCIII
-7
-6
-5
-4
-3
-2
-1
0
BMI Category
RefPe
rce
nt
We
igh
t L
os
s (
%)
Unadjusted Ptrend = 0.60
Adjusted Ptrend = 0.84
OBCIII
OBCIIOBCIOW
-7
-6
-5
-4
-3
-2
-1
0
Education
Less than HS HS or GED College University
RefPe
rce
nt
We
igh
t L
os
s (
%)
Unadjusted Ptrend = 0.46
Adjusted Ptrend = 0.33
Series1
-7
-6
-5
-4
-3
-2
-1
0W
eig
ht
Lo
st
(kg
)
Ref
*
* *
White Asian OtherAFHeritage
Ethnicity
Next steps for Wharton Medical Clinic
Research Current Studies
Comparison metabolically normal obese vs metabolically abnormal obese (submitted)
Economic analysis of effectiveness data Analysis of attrition rates OSA in patients unwilling to use CPAP -
randomized to GLP1 analogue vs placebo
PGX fibre in diabetics (placebo controlled)
Application of model to family medicine clinics
Recent publication for the Wharton Medical
Clinic
Research in non-surgical bariatric medicine
We are obligated to complete research in this area – we are still in our infancy.
Conclusion and Questions
Statement: Community based bariatric medicine is necessary Question: How are we going to pay for
it? Statement: Results from WMC are
promising Question: How can it get better, more
efficient and even more cost effective Are we Ready for community based
practice? Do we have a choice?
Thank You!
Sarah Vanderlelie, BSc
Jennifer Kuk, PhD Arya Sharma, MD Saaqshi Sharma,
MSc Rebecca Liu, MSc Marcia Villafranca Blair Leonard, MD
WMC Team