Sharon Alger-Mayer

The Lifestyle Challenge Program: A Multidisciplinary Approach to Weight Management

BACKGROUND The increasing prevalence of overweight and obesity in the US has received widespread attention and is highlighted in recent government-issued health priorities. While there are many weight loss programs in different settings, few include pharmacist involvement in spite of pharmacists’ recognized easy accessibility to the public. OBJECTIVE To provide insight into a successful, collaborative, multidisciplinary approach to weight management and to encourage pharmacists and other healthcare professionals to adopt a similar approach to patient management. METHODS Adult patients >18 years of age were recruited from an outpatient university-based setting to participate in a weight management program. The principles of the program included diet, exercise, and behavior modification. The program was conducted through weekly one-hour group sessions held over a 20-week period. Faculty involved in the program included an attending physician specializing in nutrition, a pharmacist, and a behavioral psychologist. All data are expressed as mean ± SD unless otherwise specified. RESULTS Ninety participants (74 female, mean age 48 ± 10 y) entered the program between April 2001 and April 2004. Participants had multiple obesity-related comorbid diseases. The weight of completers (n = 59) decreased from 100.9 ± 20 kg at baseline to 97.3 ± 19.5 kg at 10 weeks and 95.9 ± 20 kg at 20 weeks. Thirty-nine patients completed both baseline and final assessments, which showed improvement in health-related quality of life, binge-eating behavior, and depressive symptoms (p < 0.05). CONCLUSIONS This program is a successful multidisciplinary model for the management of overweight and obese patients in an outpatient-based hospital setting.

Pharmacist Intervention Enhances Adherence to Orlistat Therapy

BACKGROUND: Pharmacists, especially those in community practice, should increase their level of intervention in dealing with the nationwide epidemic of obesity since they interact with large numbers of the public on a regular basis. We hypothesized that patients who receive medication for weight loss may have an improved therapeutic outcome if they received additional support from their community pharmacist. OBJECTIVE: To evaluate the impact of pharmacist support on patient persistence with orlistat. METHODS: Pharmacists were trained in basic obesity management skills. Patients who were prescribed orlistat and attending an outpatient nutrition program were invited to participate in the study. All patients agreed to receive pharmaceutical care. Those who lived where the service was available were assigned to the intervention (I) group and those who did not were assigned to the control (C) group. All patients received usual care provided by the outpatient clinic. RESULTS: Thirty patients, 15 in the I group and 15 in the C group, were recruited. Both groups were predominantly women (87%) with a mean ± SD age of 43.8 ± 9.7 years. Patients in the I group had significantly greater persistence with orlistat therapy as assessed by duration of therapy (p = 0.006) and number of patients completing the 26-week study (7 I, 2 C; p = 0.046). There was no significant difference in percent of weight loss between groups (p > 0.05). CONCLUSIONS: In this pilot study, patients receiving pharmaceutical care took orlistat longer than the controls and had improved outcome with orlistat therapy.

Management of iron deficiency and anemia after Roux-en-Y gastric bypass surgery: An observational study

BACKGROUND Iron deficiency (ID) is common after Roux-en-Y gastric bypass surgery (RYGB). Optimal iron management in this population is unclear. The objective of this study was to assess our management of RYGB patients with ID and anemia. METHODS Clinic visit records of RYGB patients with ID or anemia from January 1, 2008, to February 1, 2010 were evaluated. Demographic characteristics, postsurgery iron and anemia indices, and prescribed treatments were recorded. Three separate definitions for ID and anemia were used (standard textbook, ASBMS, and recent literature). An intravenous iron protocol was later implemented, and follow-up laboratory values were obtained. RESULTS A total of 125 with ID or anemia (89% female, 86% Caucasian), mean (SD) age 44.7 (8.6) years, and BMI 47.3 (10.8) kg/m(2) at time of RYGB, were included. Proportion of values meeting criteria for ID or anemia at first follow-up: standard textbook, hemoglobin (Hb, 35%), transferrin saturation (Tsat, 48%), ferritin (28%); ASBMS, ferritin (43%); recent literature, ferritin (58%), serum iron (21%). At mean follow-up of 45.7 (43) months, oral iron (n = 49) or intravenous iron (n = 4) had been prescribed for 53 (42.4%) patients, and 32 (25.6%) patients received multiple blood transfusions. Nine patients received intravenous iron using the new protocol (400-1400 mg), resulting in increases in Hb (1.8 g/dL; P<.05) and ferritin (31.8 ng/mL; P< .002). CONCLUSION Iron management was inadequate. Hematologic values often were deficient for sustained periods. Initially, few patients received intravenous iron after oral iron failure, many received no iron supplementation, and there was high use of blood transfusions. Subsequently, administration of intravenous iron was beneficial.

Medication Use Patterns after Gastric Bypass Surgery for Weight Management

BACKGROUND: Bariatric surgery, commonly gastric bypass, is an effective intervention in achieving sustained weight loss in patients with a body mass index (BMI) >40 kg/m2. Currently, there are few data in the literature describing medication use after bariatric surgery. OBJECTIVE: To document the change in medication use patterns over a 2-year period in patients who had gastric bypass surgery. METHODS: Institutional review board approval was obtained for this ongoing, prospective longitudinal study. Adults (>18 y) scheduled for gastric bypass surgery were recruited. Clinical and demographic data, including age, gender, weight, height, BMI, number of obesity-related comorbidities, and number of medications and nutritional supplements, were obtained by medical chart review. RESULTS: One hundred fourteen patients (87 females) were recruited. The mean ± SD age was 45 ± 9 years. Patients had multiple obesity-related comorbid diseases for which they were receiving medication. Drug therapy for diabetes and hypertension was significantly reduced (p < 0.05). All patients were required to take additional nutritional supplements and medications associated with surgery postoperatively. CONCLUSIONS: Bariatric surgery has a positive benefit in terms of reduction intake of medication associated with obesity-related comorbid disease. However, there is limited reduction in the overall number of drugs and supplements being consumed by the patient, especially during the first year postoperatively.

Proposal for Medical School Nutrition Education Topics and Recommendations

The mission of increasing the number of physician nutrition experts requires focused nutrition education directed at medical students across the 4-year curriculum and into postgraduate training. Courses should be horizontally and vertically integrated, bridging the basic sciences and clinical medicine. It is anticipated that the Liaison Committee on Medical Education and Association of American Medical Colleges will require competency in nutrition with emphasis on preventive and therapeutic applications. Barriers to implementation of nutrition courses can be overcome by using innovative teaching in association with cooperative course directors. Analysis of prior governmental efforts, through the Nutrition Academic Award, provides a basis for targeting fundamental knowledge and creative methods for achieving educational goals. Recommendations for short-term and long-term ideas for increasing the number of adequate physician nutrition experts are offered.

Specialty Residency Training in Medical Nutrition Education History and Proposal for Improvement

Nutrition education among residents in training is at a critical juncture. There is a general lack of a unified curriculum, a lack of nutrition physician mentors, and a failure to properly train physicians about nutrition. In surveys, residents in training have acknowledged their minimal nutrition education. Published data and training experiences suggest the importance of creating physician mentors in nutrition who are embedded in residency training programs. The development of recurrent short-term nutrition credentialing courses and online nutrition tool kits is also thought to be important in future residency training.

Medication Associated with Weight Gain May Influence Outcome in a Weight Management Program

BACKGROUND Weight gain is a commonly overlooked adverse effect of some medications that potentially confounds weight loss efforts in individuals who are overweight and obese. OBJECTIVE To determine the frequency of use of drugs associated with weight gain by participants and the effect on outcome in a weight management program. METHODS Adult patients >18 years of age were recruited from an outpatient, university-based setting to participate in a 20-week structured weight management program. RESULTS Ninety patients (74 women) were recruited (mean [± SD] age 48 ± 10 y, mean body mass index 37 ± 6 kg/m 2 ). Patients had multiple diseases including type 2 diabetes mellitus (n = 23), hypertension (n = 48), depression (n = 18), and dyslipidemia (n = 9). The median number of drugs per patient was 4.0 (range 0–15). The median number of drugs associated with weight gain was zero (range 0–3). Forty-three (48%) patients were taking at least one of these agents, including β-blockers (n = 18), selective serotonin-reuptake inhibitors (n = 18), sulfonylureas (n = 7), insulin (n = 9), and thiazolidinediones (n = 6). Seven patients completed ≤6 weeks of the program and were excluded from further analysis, and 83 patients completed 10 weeks. Of these 83 patients, 39 had lost ≤2% of their initial weight; 23 (59%) of those 39 were taking drugs associated with weight gain. Fifty-nine patients completed the full 20 weeks. The mean overall weight loss of completers was 4.8 ± 5.0% (range −5.9 [gain] to 17.1% [loss]) at 20 weeks. CONCLUSIONS Patients taking WGDs weighed more at baseline and were less likely to lose weight in this program. Attention should be given when prescribing such medications to obese patients, as this may negatively influence their weight management.

Board Certification and Credentialing in Nutrition

Board certification and credentialing in nutrition for physicians are problematic issues. Many board examinations are offered, but have few candidates and poor recognition. This discussion focuses on the feasibility of establishing a single board examination body. Some key considerations were identified to improve credentialing and examination in nutrition for physicians. Increasing the number of nutrition physicians and improving recognition of their credentials should ultimately translate to better patient health and safety. Consolidation of board examinations may be in the best interest of physician nutritionists.

Use of Orlistat 60 mg in the Management of Weight Loss before Bariatric Surgery

BACKGROUND: Patients undergoing gastric bypass surgery are usually required to lose weight during the preoperative phase of their management. For some individuals, this is difficult to achieve with diet and exercise alone, and the use of weight loss medication may be considered a treatment option. OBJECTIVE: To evaluate the use of orlistat 60 mg taken up to 3 times daily as an adjunct to achieve the 10% preoperative weight loss recommended in this bariatric program prior to gastric bypass surgery. METHODS: The aim was to recruit 50 patients (25 treatment, 25 controls) who were in the preoperative phase of their bariatric program. Patients were referred by their physician. Control subjects were selected from individuals who were eligible but not interested in participating in the study during the same period. All patients received usual care. RESULTS: Nineteen patients (5 males) and 19 age- and sex-matched controls were included. The mean (SD) initial body mass index for the treatment versus control group was, respectively, 49.5 (10.5) versus 47.2 (4.9) kg/m2 (p = 0.559). At 3 months, the percent excess weight (EW) loss was 2.4 (3.8) (n = 15) versus 5.5 (7.6) (n = 19) (p = 0.111) and the percent total body weight (TBW) loss was 1.2 (1.9) versus 2.9 (4.1) (p = 0.103). At 6 months, the percent EW loss was 3.6 (6.4) (n = 9) versus 10.2 (8.0) (n = 16) (p = 0.036) and the percent TBW loss was 2.0 (3.4) versus 5.4 (4.2) (p = 0.048). CONCLUSIONS: Some patients felt that orlistat was beneficial for weight loss; however, overall, they did not show benefit from its addition to their preoperative weight loss management.