Nadia Ahmad, MD, MPH

Founding Director

Obesity Medicine Institute, Dubai

American Board of Obesity Medicine

drahmad@obesitymedicineinstitute.com

971 55 452 8476

February 23, 2016

Polypharmacy

Cancer

Fatty

Liver

GERD PCOS

Infertility

Obstructive

Sleep apnea

Venous

stasis Peripheral

vascular

disease

Back pain

Hyperlipidemia

Heart

disease

Arthritis

Hypertension

Diabetes

Harmful Diet

Physical

Inactivity

Stress

Sleep

Problems

Inadequate

Follow up

Emotional

Eating

Binge Eating

Bulimia

Bipolar

Anxiety

Depression

Poor social

support

Social

Stigma

Low

Self-esteem

Poor insight

Low

Motivation

180

WASHINGTON – Under Obamacare, doctors can now refuse obese patients. And they

are doing it! Obstetrics-gynecology practices across the country have set weight limits

for new patients.

If you’re obese – you will not be allowed to schedule an appointment. If you try to come

to the office, you will be thrown out. Doctors said the main reason was their exam

tables or other equipment can’t handle people over a certain weight, but at least six

said heavy women run a higher risk of complications.

“People don’t realize the risk we’re taking by taking care of these patients,” the

newspaper quoted Dr. Albert Triana of South Miami as saying. “There’s more risk of

something going wrong and more risk of getting sued. Everything is more complicated

with an obese patient in GYN surgeries and in pregnancies,” he told WWN.

Under Obamacare, it is not illegal for doctors to refuse overweight patients, and

according to the Michelle Obama Rider to the Affordable Healthcare Bill, doctors

MUST refuse to care for obese patients.“People need

to know that obesity will NOT be tolerated in our

society any longer,” said First Lady Michelle Obama.

Weight cutoffs have already been enacted by doctors

in thirty-one states. Many who have long complained about high numbers

of lawsuits after difficult births and high rates for medical-malpractice insurance.

So for all those that are overweight and obese –

you’re on your own from now on!

“Doctor’s Won’t Take Fat Patients”

www.weeklyworldnews.com, May 17, 2011, Tapp Vann

3 Principles of Obesity Management

Principle 1: Obesity has biological underpinnings

weight maintenance

energy

ingested

energy

expended

Physics: First Law of Thermodynamics

Energy

InEnergy

Used

Net Energy

Gain/Loss

If a 35 year-old 70kg man drinks 5 liters of water in a 24-hour period, what is new his blood volume?

Baseline blood volume = 5 L

Water

Water

InWater

out

Net Change

in Blood Vol.

If a 35 year-old 70 kg man drinks 5 liters of water in a 24-hour period, what is new his blood volume?

Baseline blood volume = 5 L

Urinary output = 1 ml /kg/ hr = 1.7 L

Insensible losses = 0.8 L

Water

Water

InWater

out

Net Change

in Blood Vol.

5 L 2.5 L 2.5 L

New blood volume: 7.5 L !

If a 35 year-old 70 kg man drinks 5 liters of water in a 24-hour period, what is new his blood volume?

Baseline blood volume = 5 L

Urinary output = 1 ml /kg/ hr = 4.2 L

Insensible losses = 0.8 L

Water

Water

InWater

out

Net Change

in Blood Vol.

5 L 5 L 0 L

New blood volume: 5 L

Water balance is complex and regulated

Berthoud et al. Physiology. 2008;23 75-83.

Energy balance is complex and regulated

Berthoud et al. Physiology. 2008;23 75-83.

Energy balance is complex and regulated

•Serotonin

•Dopamine

•Catecholamines

•Endocannabinoids

•GABA

•Glutamine

NEUROTRANSMITTER SYSTEMS

•Sympathetic System

•Vagal System

•Myenteric PlexusNEURAL PATHWAYS

•Leptin / Adiponectin

•Ghrelin

•CCK

•GLP-1 / PYY

•Oxyntomodulin

•GIP

HORMONES

Isn’t everything in the body regulated?

Body Temperature

Heart rate

Respiratory rate

Blood pressure

CSF pressure

Urine output

Lung volumes

Blood volume

CSF volume

Oxygen saturation

Serum pH

Cholesterol

Bile production

Blood glucose

Serum sodium

Serum calcium

Vitamin D

RBC mass

Bone mass

Muscle mass

Liver mass

Milk production

Ovulation

Coagulation/clotting

Hair growth

Skin color

Fat mass

Physics: “First Law of Thermodynamics”

Energy

InEnergy

Used

Net Energy

Gain/Loss

Physiology: “First Law of Obesity”

Energy

InEnergy

Used

Net Energy

Gain/Loss

“The Adipostat”

John R. Speakman et al. Dis. Model. Mech. 2011;4:733-745

Principle 1: Obesity has biological underpinnings

Principle 2: Obesity is a heterogeneous condition

Prader- Willi syndrome

Bardet-Biedl syndrome

Alström syndrome

Hypothalamic

Hyperphagic

Thermogenesis deficient

Circadian-disrupted

Stress-induced

Viral

Central

Peripheral

Diffuse

Neonatal

Early childhood

Peripubertal

Gestational

Menopausal

“Healthy”

Metabolic

Leptin deficiency

LepR deficiency

MC4R deficiency

aMSH deficiency

Sim-1 deficiency

PC-1 deficiency

KSR2 deficiency

MRAP2 deficiency

SH2B1 deficiency

BDNF deficiency

trkB deficiency

Carpenter syndrome

Cohen syndrome

Ayazi syndrome

MOMO syndrome

Rubenstein-Taybi syndrome

Fragile X syndrome

BFL syndrome

Albright osteodystrophy

Inflammatory

Diet-dependent

Exercise-sensitive

Sleep-sensitive

Insulin-induced

Steroid-induced

Progesterone-induced

Psychotropic-induced

Antibiotic-induced

Endocrine disruptor

Phentermine-responsive

Lorcaserin-responsive

Topiramate-responsive

Metformin-responsive

Bupropion-responsive

GLP-1 responsive

Bypass-responsive

Bypass-resistant

Gastric band-responsive

The Obesities: 57 and counting…

Courtesy of Lee M. Kaplan, MD, PhD, Harvard Medical

School

Biological complexity leads to clinical heterogeneity

Determinants of

heterogeneity

Environment and lifestyle: The modifiable factors

1

2

3

4

5

6

Medications

Diet

Activity

Sleep

Stress

Circadian rhythm

Common medications alter energy regulation

1.

Weight gain-

promoting

medications

Medications that promote weight gain

CNS drugs Endocrine agents Miscellaneous

Anti-epileptics

eg.valproate

Anti-depressants

Atypical Antipsychotics

eg. olanzipine

Glucocorticoids

eg. prednisone

Hormonal

contraceptives

eg. medroxyprogesterone

Diabetes agents

Beta blockers

eg. metoprolol

Antihistamines

eg. diphenhydramine

Lithium

Others

eg.

venlafaxine,mirtazapine

Tricyclic agents

eg. nortriptyline

SSRIs

eg. paroxetine

Thiazolidenediones

eg. pioglitazone,

Sulfonylureas

eg. glyburide

Insulin

Sleep aids

eg. zolpidem

Leslie, et al. QJM. 2007;100: 395-404.

Specific nutrients alter energy regulation

2.

Diet

Refined carbohydrates

Saturated fats

3.

Activity

Unhealthy muscle alters energy regulation

Adipose tissueCalorie expenditure

Muscle

↑insulin

sensitivity

Muscle

growth

factorsImproved

fat oxidation

↑ Energy

Expenditure

Appetite

changes

Myokines ?

nerve signals

↑ Leptin

signaling

Brain

4.

Sleep

Inadequate sleep alters energy regulation

Sleep

Deprivation

Leptin

Ghrelin

Insulin

Cortisol

Altered

thermoregulation

Fatigue

Obesity

Patel & Hu. Obesity. 16(3): 643-53. 2008; Knutson et al. Sleep Med Rev. 11(3): 163–78. 2007.

5.

Stress

Stress alters energy regulation

Decreased

Metabolic Rate and

Increased Food

Intake

Increased Hedonic

Drive and

Consumption of

Palatable Foods

Stress

Increased Cortisol

Hyperinsulinemia/

Insulin resistance

Leptin Resistance

Sinha R, Jastreboff AM. Biol Psychiatry. 2013; 73(9): 827-35.

6.

Circadian

rhythm

Circadian rhythm is linked to metabolism

Froy O, Miskin R. Aging. 2010; 2(1): 7-27.

6.

Circadian

rhythm

Disrupted circadian rhythm alters energy regulation

Biological complexity leads to clinical heterogeneity

Determinants of

heterogeneity

Epigenetic and developmental factors

http://contemporaryobgyn.modernmedicine.com/

Predictors

Maternal obesity

Maternal nutrition

Maternal activity

Maternal stress

BPA exposure

Infant feeding

Infant sleep

Adverse Outcomes

Rapid fetal growth

High birthweight

Rapid infant gain

High infant weight

Childhood obesity

Adolescent obesity

Adult obesity

Epigenetic and developmental factors

Childhood

MenarchePregnancy

Birth

Menopause Post-partum

Transgenerational

spread

High birthweight

LGA, macrosomia

Childhood overweight

and obesity

Increased

visceral

adiposity

Post-partum

weight

retention

Excess

gestational

weight gain

Increased

adipose

accumulation

“What kind of apple are you” is the question

Age of onset Taste preferences

Fat distribution

Comorbidities

Stress response

Sleep patternsPropensity toenjoy activity

Cravings

Hunger cues Satiety cues

Response to macronutrients

Weight gain with meds

?

Principle 2: Obesity is a heterogeneous condition

Diet

Activity

Stress

Sleep

Circadian

Rhythm

Medication

Intrauterine

Environment

Childhood

Puberty

Pregnancy

Menopause

Developmental

Effects

Modifiable

Factors

Principle 3: There is broad variability in treatment response

N

Weight Loss

Heterogeneity leads to variation in treatment response

0

5

10

15

20

25

30

Drug (Liraglutide)

Weight loss varies widely among patients

0

5

10

15

20

25

30

Diet (Low-carbohydrate)

Surgery (Gastric Bypass)Device (Duodenal liner)

0

5

10

15

20

25

30

10-1

5 G

ain

5-1

0 G

ain

0-5

Gain

0-5

5-1

0

10-1

5

15-2

0

20-2

5

25-3

0

30-3

5

35-4

0

40-4

5

45-5

0

0

5

10

15

20

25

30

10-1

5 G

ain

5-1

0 G

ain

0-5

Gain

0-5

5-1

0

10-1

5

15-2

0

20-2

5

25-3

0

30-3

5

35-4

0

40-4

5

45-5

0

>5

0

Patients

(%

)P

atients

(%

)

Courtesy of Lee M. Kaplan, MD, PhD, Harvard Medical

School

N

Weight Loss

Aim High: Target Responders

Comorbidityreduction

Stress reduction Sleep strategies

SpecificActivities

Different Medications

Specific diets

Switching meds

?

N

Weight Loss

Tri

al 1

N

Weight Loss

Tri

al 2

N

Weight Loss

Tri

al 3

Trialing Treatments

Assessment:

“You need to lose weight”

Recommendation:

“Eat less, move more”

Trial:

Patient attempts to “eat less, move more”

Result:

Limited, weight loss does not meet expectation

Interpretation:

“I failed” “She’s non-compliant”

We need to break the cycle

Diet

Activity

Stress

Sleep

Circadian

Rhythm

Medications

Intrauterine

Environment

Childhood

Puberty

Pregnancy

Menopause

Genes

Age

Gender

Race

Developmental

Effects

Fixed

Factors

Adipose

PhysiologyModifiable

Factors

Depression

Eating

Disorders

Anxiety

Other

psychiatric

issues

Treatable

Issues

Food

Industry

Built

Environmen

t

Media

Work

Schedules

Socio-political

& Cultural

Influences

high low

Opportunity for Clinical Intervention

Causes of Obesity

Summary: 3 Principles of Obesity

• Obesity has complex biological

underpinnings. In order to address obesity, it

is paramount that we better understand its

pathophysiologic basis.

• Obesity is a very heterogeneous condition

that calls for a more nuanced assessment of

the patient to identify specific subtypes.

• There is broad variability in treatment

response and it is likely that different

subtypes of obesity respond best to different

treatments. The practitioner should be ready

to trial multiple treatments and treatment

modalities in each patient.