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Role of Private Bariatric Medical Centres ARE WE READY?

Role of Private Bariatric Medical Centres ARE WE READY?. Dr. Sean Wharton, MD, FRCPC Internal Medicine Wharton Medical Clinic Adjunct Professor – York University Lead Author – Obesity Section - CDA Guidelines. CABPS, June 2012. Disclosures. G rants/support CIHR

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Role of Private Bariatric Medical Centres ARE WE READY?

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  1. Role of Private Bariatric Medical CentresARE WE READY? Dr. Sean Wharton, MD, FRCPC Internal Medicine Wharton Medical Clinic Adjunct Professor – York University Lead Author – Obesity Section - CDA Guidelines CABPS, June 2012

  2. Disclosures • Grants/support • CIHR • Heart and Stroke Foundation • MITACS – Research • Honoraria/Advisory Board • Novo-Nordisk • Merck • Bristol Myers Squibb • Abbott Pharmaceuticals • Eli-Lilly • AstraZeneca

  3. Objectives Discuss the current environment of community based bariatric medicine Example of a publically funded community based weight management clinic.

  4. 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

  5. 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.

  6. AnswersCommunity Bariatric Medicine • Efficient System – demand is great • Multi-disciplinary • Cost-effective • Family/childhood obesity a priority

  7. 115 Programs Analyzed 31 Surgical Programs 2 Surgical Assessment Centres 82 Non-surgical Programs 32 Community-based (group session, gym) 41 Primary Health Care (MD, nurse, dietitian) 7 Hospital-based

  8. 115 Programs

  9. 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

  10. 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

  11. 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.

  12. 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

  13. Wadden et al. NEJM; Nov 14, 2011

  14. Important aspects of a weight management clinic • Cost • medical supervision • frequent visits • no pressure/non judgmental • emotional support • nutritional support • convenient location with parking

  15. How frequently would you like to come to a professional centre for a weigh in?

  16. 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

  17. 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

  18. 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

  19. 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

  20. WMC Program Flowsheet 1. FD - ASK 2. ASSESS 3. AGREE 4. ADVISE 5. ASSIST WEEKLY WEIGH-INS ENCOURAGED – not billed to OHIP

  21. BE #1 Notes

  22. BE #1 Notes

  23. BE #1 Notes Weight, Ht, BP, WC/HC

  24. BE #1 Notes BE #2 Presentations

  25. BE #1 Notes BE #2 Presentations BE #5 Individual visit BE #4 Individual visit BE #3 Individual visit

  26. BE #1 Notes BE #2 Presentations BE #5 Individual visit BE #4 Individual visit BE #3 Individual visit

  27. BE #1 Notes BE #2 Presentations BE #5 Individual visit BE #4 Individual visit BE #3 Individual visit

  28. WMC - Lectures Educational 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

  29. RMR Machine

  30. Comparison of Group vs. Individual Treatment for Weight Loss: 6 months Group Treatment Preferred Non-Preferred Individual Treatment Preferred Non-Preferred Weight Loss (in kg) p < .02 Renjilian, Perri et al. J Consult ClinPsychol 2001; 69:717-721.

  31. 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

  32. Barry’s Weight Loss Graph

  33. 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

  34. Feasibility of a interdisciplinary program for weight management in Canada Sean Wharton MD; Sarah VanderLelieB.A.Sc; Saaqshi Sharma M.Sc; Arya Sharma MD; Jennifer L. Kuk PhD Canadian Family Physician, Feb 2012;852:32-8

  35. 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

  36. Number of Patients Disease Canadian Family Physician, Feb 2012;852:32-8

  37. Wharton et al. Can FamPhys, 2012;852:32-8

  38. Prevalence of WMC Patients attaining 5% and 10% Weight Loss (18 months) 1,562 patients

  39. 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

  40. Results- Prevalence of MNOB and MAOB Sub-clinical cutoffs Clinical cutoffs Prevalence (%) Baseline Follow-up Number of metabolic risk factors

  41. Sex Male Female Percent Weight Loss (%) Ref Unadjusted data Data adjusted for independent variables: sex, age group, BMI class, education, ethnicity and smoking status and treatment duration)

  42. Age Group 18-49 49-64 >64 Percent Weight Loss (%) * * ** Ref Unadjusted Ptrend = 0.004 Adjusted Ptrend = 0.007

  43. BMI Category OW OBCIII OBCI OBCII Weight Lost (kg) Ref * Unadjusted Ptrend <0.0001 Adjusted Ptrend <0.0001

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