Pharmacy & Therapeutics - December 2008 - (Page 725)

CONTINUING EDUCATION CREDIT Table 1 Classification of Overweight and Obesity by Body Mass Index (BMI), Waist Circumference, and Associated Disease Risk BMI (kg/m²) Obesity Class Disease Risk (Relative to Normal Weight and Waist Circumference)* Men: ≤40 inches (≤102 cm) Women: ≤35 in (≤88 cm) Underweight Normal weight‡ Overweight Obesity 40 inches (>102 cm) > 35 inches (>88 cm) — — High Very high Very high Extremely high * Disease risk for type-2 diabetes, hypertension, and cardiovascular disease. ‡ Increased waist circumference can also be a marker for increased risk even in persons of normal weight. Adapted from Obesity: Preventing and Managing the Global Epidemic. WHO, 1997.3 therapy have not produced satisfactory outcomes. The weight loss achieved with bariatric surgery has been shown to improve a variety of comorbid conditions such as diabetes, hypertension, lipid abnormalities, obstructive sleep apnea, and female urinary stress incontinence. 6 Patients are eligible for surgery if they have a BMI of 40 kg/m2 or higher, and potential benefits of surgery should outweigh the risks. The National Table 2 Average Number of Calories Expended by a 154-Pound Person Engaging in Physical Activity Calories/hour* (approx.) Moderate activity Hiking Light gardening/yard work Dancing Golf (walking and carrying clubs) Bicycling ( 10 mph) Swimming (slow free-style laps) Aerobics Walking (4.5 mph) Heavy yard work (chopping wood) Weight lifting (vigorous effort) Basketball (vigorous) 370 330 330 330 290 280 220 180 590 590 510 480 460 440 440 440 * The number of calories burned per hour is higher for persons who weigh more than 154 pounds (70 kg) and lower for persons who weigh less than 154 pounds. Adapted from The Dietary Guidelines for Americans 2005. Available at: www.webmd.com.5 Institutes of Health (NIH) suggests that patients with a BMI of 35 kg/m2 or higher with a comorbidity such as severe diabetes, sleep apnea, or joint disease may also be candidates for surgery. In February 2006, the Centers for Medicare and Medicaid Services (CMS) approved reimbursement of weight-loss surgery for patients with a BMI of 35 kg/m2 or higher with one comorbidity. Weight loss as an outcome of surgery can occur by two mechanisms: gastric restriction and malabsorption or a combination of both. Gastric restriction encompasses such procedures as the vertical banded gastroplasty and the laparoscopic adjustable band. Gastric bypass involves both mechanisms to achieve weight loss, whereas the biliopancreatic diversion with duodenal switch involves a technique resulting in malabsorption. The vertical banded gastroplasty that was popular in the 1980s has been replaced by alternatives because of low satisfaction rates. Adjustable band. The least invasive of the bariatric surgical procedures is the laparoscopic adjustable band. A silicone band is placed around the first portion of the stomach to form a small pouch and stoma. Although the stomach is not permanently altered, risks associated with this procedure include erosion of the band into the stomach, obstruction, infection, and long-term esophageal motility sequelae. The average one-year weight loss is 45% of excess weight. Gastric bypass. The most commonly used procedure in the U.S. is the Roux-en-Y gastric bypass. The surgeon creates a small pouch, and a portion of the small intestine is bypassed. Patients lose an average of 60% to 70% of their excess weight 9 to 14 months after surgery, and most patients maintain much of the initial weight loss at 10 years. The Swedish Obesity Study compared more than 2,000 subjects undergoing bariatric surgery (gastric bypass, vertical banded gastroplasty, and banding) with matched controls receiving conventional treatment ranging from sophisticated lifestyle intervention and behavior modification to no treatment at all.6 Follow-up visits at 10 years showed that body weight increased in the control group and weight loss had stabilized Vol. 33 No. 12 • December 2008 • P&T® 725 http://www.webmd.com

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Pharmacy & Therapeutics - December 2008 Contents Editorial Medication Errors Prescription: Washington New Drugs/Drug News/ New Medical Devices Drug Forecast Interpreting Estimates of Treatment Effects Chemotherapy Foundation Symposium XXVI: Innovative Cancer Therapy for Tomorrow Third Annual Onmark National Payor/Provider Forum Fourth Annual Ophthalmic Drug Development and Delivery Summit Classification and Pharmacological Management Of Obesity CE Test and Forms Season’s Greetings: Thanks to Our Readers and Reviewers

Pharmacy & Therapeutics - December 2008

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