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