Connections: Obesity has more than one cause and solution | Summer 2018

Connections is a quarterly newsletter for primary care providers covering the latest developments and advances in medicine at OHSU. Learn about the many clinical, education and outreach resources available to you and your patients.

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From OHSU Bariatric Services

Dr. Farah Husain, division head of Bariatric Surgery

Farah A. Husain, M.D., FACS, FASMBS

Dr. Husain is a fellowship-trained bariatric surgeon and the division chief of Bariatric Services. She advocates for patients with obesity, so they can receive care without bias and has the goal of creating a comprehensive obesity treatment center for all ages.

Obesity options for adolescents

At this time, most weight-loss medications aren’t approved for children under 18. OHSU Doernbecher Children’s Hospital offers an intensive lifestyle (diet and exercise) program for this age group. We do not currently offer bariatric surgery to pediatric patients but may in the near future as OHSU is seeking accreditation for adolescent bariatric surgery.

Understanding obesity as a disease rather than a lifestyle choice

Data collected by the Centers for Disease Control indicate that more than one-third (36.5 percent) of U.S. adults have obesity, a condition proven to shorten life span and cause a cascade of medical complications.

Traditionally, we have reduced obesity to the simple equation of calories in versus calories out, but now we recognize that body mass index is multifactorial. There is something much more powerful at work than just calories for many people who find it harder to maintain a lower body weight.

An interesting demonstration of this concept is that some Type 2 diabetes patients no longer need insulin the day after bariatric surgery, before any actual weight loss. This suggests a complex system not just linked to calories but involving other factors such as the balance of the microbiome, GI hormones and the type of calories consumed in addition to the quantity.

To positively influence this trend in high BMI, we need a clearer pathway for treating obesity that includes education in diet and exercise, medication and evaluation for surgery.

Life-altering yet underutilized bariatric surgery

Less than 1 percent of the patients who qualify for bariatric surgery seek it, even though outcomes show its efficacy. With surgery, patients will lose 20–25 percent of their body weight, compared with 8–10 percent with medication and 1–2 percent with diet/exercise regimens.

Historically, obesity treatment had a patchy record of success and safety. However, in the last 20–30 years, we have fine-tuned gastric bypass surgery and tightened patient criteria to produce excellent outcomes. Surgery provides the largest and most sustained weight loss option, which leads to significant improvements in co-morbidities and risk factors. Patients with chronic conditions such as diabetes, high blood pressure and fatty liver disease show improvement in these diseases following surgery. Many patients can reduce their dependence on medications and improve their quality of life as a result.

Who are the other 99 percent?

For patients with 35 BMI or higher, a surgical evaluation could be beneficial. For Type 2 diabetes patients, the threshold may be lower, as there are compelling studies showing marked improvement following surgery for those with BMIs ranging from 30–35.

Most insurance companies have some coverage for bariatric surgery now. The Oregon Health Plan made a significant change this year to come closer to the standard by validating patients over 35 BMI with two co-morbidities. Unfortunately, requiring an obesity-related co-morbidity to justify surgery works against younger patients who may receive the greatest benefit from early intervention, but have yet to develop serious medical conditions related to obesity.

The pathway to surgery is an extensive process

To optimize a patient for bariatric surgery medically, physically and emotionally can take from six weeks to six months at OHSU, based on the individual. Serious medical conditions — heart transplants, kidney failure — may not be a barrier to surgery but do need appropriate preparation.

Patients also work with a physical therapist and dietitian to implement exercise and nutrition modifications before surgery. Intensive psychological counseling is also part of the preparation, helping patients identify barriers to success and healthy coping strategies for stress. After bariatric surgery, we follow our patients every three months the first year and then offer annual diet and lab monitoring. However, many patients prefer to rely on their primary care provider for ongoing monitoring. We are happy to communicate with PCPs about this long-term care. We also offer support groups and a closed Facebook page for patients looking for community support.

Moving beyond motivation to intervention

A remaining challenge is fighting a pejorative opinion among the public and even in health care that obesity is the result of self-inflicted behavior. There is plenty of data showing that diet and exercise don’t work as well as medication and surgery, both initially and over time. Of course, we should always offer diet and exercise education to all, but for those whose BMI puts them at high risk, the alternatives can be more impactful.

When to refer or consult

For patients over 18 years old who have:

  • BMI higher than 40.
  • BMI of 35 or higher with one or more obesity-related conditions, such as arthritis, Type 2 diabetes, heart disease, high blood pressure or cholesterol, sleep apnea or an inability to keep a healthy weight loss with previous efforts.

Stepped treatment approach to obesity

When patients reach the threshold of 27 BMI, physicians may consider medication therapy in addition to diet and exercise education after ruling out eating disorders. Phentermine is the most established and affordable. Other medications shown to help in weight loss are Qsymia, Topamax, Saxenda and Contrave. Most of these medications work at the central brain level to alter metabolism and hunger pathways. It is important to keep patients on these medications if they find success with them. If a patient’s BMI continues to hover in a dangerous range, a surgical evaluation can be the next step.

Contact us

The OHSU Bariatric Services team is available to answer questions about gastric surgeries and procedures. If you have questions or would like to refer a patient for evaluation, please call the OHSU Physician Advice and Referral Service at 503-494-4567.