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 ID: 1039218
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1. Role of Private Bariatric Medical CentresARE WE READY?Dr. Sean Wharton, MD, FRCPCInternal MedicineWharton Medical ClinicAdjunct Professor – York UniversityLead Author – Obesity Section - CDA GuidelinesCABPS, June 2012
2. DisclosuresGrants/supportCIHRHeart and Stroke FoundationMITACS – ResearchHonoraria/Advisory BoardNovo-NordiskMerckBristol Myers SquibbAbbott PharmaceuticalsEli-LillyAstraZeneca
3. ObjectivesDiscuss the current environment of community based bariatric medicineExample of a publically funded community based weight management clinic.
4. Current Environmentof Medical Bariatric CentresTertiaryHGHOttawa CivicEdmonton Capital Region – Weight Wise Community PracticesCommercialWeight WatchersBernstein’sHerbal MagicEvidence Based PracticesBMI (Bariatric Medical Institute)Wharton Medical ClinicFamily Medicine PracticesYoni Freedhoff, MD
5. Questions?Community Based Bariatric ProgramsStandardizationFunding Meal Replacements Programs, PartialFamily Doctors or SpecialistsTeamDietitians, nutritionists (bariatric educators), exercise specialists, behavioural therapist, pharmacist, social work etc.
6. AnswersCommunity Bariatric Medicine Efficient System – demand is greatMulti-disciplinaryCost-effectiveFamily/childhood obesity a priority
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9. 115 Programs Analyzed31 Surgical Programs2 Surgical Assessment Centres82 Non-surgical Programs32 Community-based (group session, gym)41 Primary Health Care (MD, nurse, dietitian)7 Hospital-based
10. 115 Programs
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12. ASPQ Criteria for Bariatric ProgramsRate of weight lossMulti-disciplinaryDietary intervention (without long term use of VLCD)Physical activityEffectivenessSafetyApproach to advertisingCost Effectiveness
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14. Pharmacotherapy3/31 – surgical programs12/82 – non-surgical program (11 PC, 1 hosp)BMI Criteria32/82 nonsurgical programs did not use BMI as entry criteria
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17. Primary care based programs show the greatest compliance. Encouraging – most accessibleAccess 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.
18. Long-term weight-loss maintenance: a meta-analysis of US studies13 Studies (VLCD and HBD)1081 pts - F/U – 4.5 yearsInitial weight loss 30.8 lbs (14%)Weight-loss maintenance 6.6 lbs (3%)40.2% of patients maintained - 5% loss at 5 yearsNNT of 2.525% of patients maintained - 10% loss at 5 yearsNNT of 5Anderson et al. Am J Clin Nutr, 2001
19. Wadden et al. NEJM; Nov 14, 2011
20. Wadden et al. NEJM; Nov 14, 2011
21. CommentsEnhanced most effective, - but even the MD alone and the lifestyle coach were effectiveMD + Coach 1/4 pts lost > 5% BWEnhanced Lifestyle1/3 lost > 5% BW Greater weight reduction with attendance at lifestyle sessions (greater with free MR, meds)
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23. Important aspects of a weight management clinicCostmedical supervisionfrequent visitsno pressure/non judgmentalemotional supportnutritional supportconvenient location with parking
24. How frequently would you like to come to a professional centre for a weigh in?
25. Wharton Medical ClinicWeight Management CentreLaunch – May 2008A large community based bariatric clinic – government funded – no charge to patients 9 Internists – 3 Nephrologist, 1 cardiologist, 2 ICU, 1 rheumatologist, 1 haematologist, 1 GIM1 Dietitian/15 Nutritionist (Bariatric Educators)Behavioural Therapy Team/Physiotherapy TeamResearch Staff
26. Bariatric EducatorsEducation/QualificationsBSc Nutrition (Guelph, UWO, Ryerson)Post WMC - 2 MDs, 2 Masters, 4 dietitian internshipSupervision/Quality ControlDietitian/MDs1/2 – 1/3 - salary of a dietitianSignificant dietary concerns – referred to the dietitian
27. WMC ClinicAdultsBMI 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 conditionsPharmacotherapySurgical Referral/Medical and Psychological Support/Pre and Post Op Management
28. Wharton Medical ClinicMay 201219,069 pts (76% women)3,734 pts current75 - 100 new pts/weekNo waiting list15-20 min GROUP education session at every visitMD sees patient at every visitVisits q 1 – 3 weeksMetabolic and CV Risk assessmentEvening Educational ClassesAggressive Diabetes Management
29. WMC Program FlowsheetWEEKLY WEIGH-INS ENCOURAGED – not billed to OHIP1. FD - ASK2. ASSESS3. AGREE4. ADVISE5. ASSIST
30. BE #1Notes
31. BE #1Notes
32. BE #1NotesWeight, Ht, BP, WC/HC
33. BE #1NotesBE #2Presentations
34. BE #1NotesBE #2PresentationsBE #3Individual visitBE #4Individual visitBE #5Individual visit
35. BE #1NotesBE #2PresentationsBE #3Individual visitBE #4Individual visitBE #5Individual visit
36. BE #1NotesBE #2PresentationsBE #3Individual visitBE #4Individual visitBE #5Individual visit
37. WMC - LecturesEducational SeminarsTopics How to complete a food journalMacro and micronutrients/label readingmeal plans/eating outdiabetic meal planningEmotional eatingstress and weight, body image, support groupActivity – pedometers, resistance bands
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40. RMR Machine
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42. Comparison of Group vs. Individual Treatment for Weight Loss: 6 months Group Treatment Preferred Non-Preferred Individual Treatment Preferred Non-PreferredWeight Loss (in kg)p < .02Renjilian, Perri et al. J Consult Clin Psychol 2001; 69:717-721.
43. Barry at 404 lbs, BMI 60Past Medical HistoryDiabetes Type 2OSA – CPAPHypertensionHigh CholesterolUrinary incontinenceHernia - ventralObesity Class IIIDevelopmental DelayIntertrigoMedicationsMetformin, GlyburideRamipril, Lipitor
44. Barry’s Weight Loss Graph
45. Barry at 231lbs, BMI 33176lbs lost, 43% WLCurrent Medical HxOSACPAP turned downDiabetes type 2Diet controlledObesity Class ICurrent MedicationsNo medicationsOff – metformin, ramipril, glyburide. Lipitor
46. Feasibility of a interdisciplinary program for weight management in CanadaSean 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
47. Descriptive sample1085 pts (3 months), 289 pts (6 months)77% femaleAge – 49.3 + 12.5 yearsBMI – 40.5 + 8.1 kg/m2
48. Number of PatientsDiseaseCanadian Family Physician, Feb 2012;852:32-8
49. 15.2% - Discontinuation of program14% within first 3 months2.2lbs (1.8%) weight lossWharton et al. Can FamPhys, 2012;852:32-815.2% - Discontinuation of program (no visit in 3 months)14% within first 3 months2.2lbs (1.8%) weight loss
50. Wharton et al. Can FamPhys, 2012;852:32-8
51. Prevalence of WMC Patients attaining 5% and 10% Weight Loss (18 months)1,562 patients
52. Discontinuation (no visit in 3 months)28.9% (N=452)lost 4.3 kg ± 6.13.7 % ± 5.0 of BW31% - 5% weight loss11% - 10% weight loss 8.4 ± 3.0 visits over 7.5 ± 1.4 months
53. Results- Prevalence of MNOB and MAOBBaselineFollow-upPrevalence (%)Clinical cutoffsSub-clinical cutoffsNumber of metabolic risk factors
54. Percent Weight Loss (%)SexRefFemaleMaleData adjusted for independent variables: sex, age group, BMI class, education, ethnicity and smoking status and treatment duration)Unadjusted data
55. Age Group* RefPercent Weight Loss (%)** * Unadjusted Ptrend = 0.004 Adjusted Ptrend = 0.00718-4949-64>64
56. Weight Lost (kg)BMI CategoryRef* Unadjusted Ptrend <0.0001 Adjusted Ptrend <0.0001OWOBCIOBCIIOBCIII
57. BMI CategoryRefPercent Weight Loss (%)Unadjusted Ptrend = 0.60 Adjusted Ptrend = 0.84OBCIIIOBCIIOBCIOW
58. EducationLess than HSHS or GEDCollegeUniversityRefPercent Weight Loss (%)Unadjusted Ptrend = 0.46 Adjusted Ptrend = 0.33
59. Weight Lost (kg)Ref* * * WhiteAsianOtherAFHeritageEthnicity
60. Bariatric Educators (BE/nutritionists) Similar to Wadden NEJM studyAffordable staff with nutrition degrees – overseen by dietitian and MDsMD has medical-legal responsibility for the BEBEs frees up time for the physician to concentrate on managing medical comorbiditiesVisit frequency correlated with greater weight lossWharton et al. Can FamPhys, 2012;852:32-8
61. Next steps for Wharton Medical Clinic ResearchCurrent StudiesComparison metabolically normal obese vs metabolically abnormal obese (submitted) Economic analysis of effectiveness dataAnalysis of attrition ratesOSA in patients unwilling to use CPAP - randomized to GLP1 analogue vs placeboPGX fibre in diabetics (placebo controlled)Application of model to family medicine clinics
62. Recent publication for the Wharton Medical Clinic
63. Research in non-surgical bariatric medicineWe are obligated to complete research in this area – we are still in our infancy.
64. Conclusion and QuestionsStatement: Community based bariatric medicine is necessaryQuestion: How are we going to pay for it?Statement: Results from WMC are promisingQuestion: How can it get better, more efficient and even more cost effectiveAre we Ready for community based practice?Do we have a choice?
65. Thank You!Sarah Vanderlelie, BScJennifer Kuk, PhDArya Sharma, MDSaaqshi Sharma, MScRebecca Liu, MScMarcia VillafrancaBlair Leonard, MDWMC Team