March/April 2016 - State of Obesity

March/April 2016

Doctors Metro MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

State of

Obesity

In This Issue:

• How does Minnesota Rank on the Obesity Scale?

Causes, Risk Factors, Treatments and Lifestyles • Shotwell and First A Physician Awards Presented • TCMS Holds Annual Meeting • Luminary of Twin Cities Medicine

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Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Robert R. Neal, Jr., M.D. Physician Co-editor Marvin S. Segal, M.D. Physician Co-editor Richard R. Sturgeon, M.D. Physician Co-editor Charles G. Terzian, M.D. Medical Student Co-editor Katherine Weir Managing Editor Nancy K. Bauer TCMS CEO Sue A. Schettle Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Andrea Westmoreland MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413.

To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of TCMS.

March/April Index to Advertisers TCMS Officers

President: Carolyn A. McClain, M.D. President-elect: Matthew A. Hunt, M.D. Secretary: Thomas E. Kottke, M.D. Treasurer: Nicholas J. Meyer, M.D. Past President: Kenneth N. Kephart, M.D. TCMS Executive Staff

Coldwell Banker Burnet..................................10 Crutchfield Dermatology.....................................

Inside Front Cover E-cigarette Webinars........................................... 4 Entira Family Clinics .......................................35

Sue A. Schettle, Chief Executive Officer (612) 362-3799; sschettle@metrodoctors.com

Fairview Health Services .................................34

Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893; nbauer@metrodoctors.com

Healthcare Billing Resources, Inc. ...............13

Karen Peterson, BSN Executive Director, Honoring Choices Minnesota (612) 362-3704; kpeterson@metrodoctors.com

Kathy Madore....................................................... 1

Lynn Betzold, Program Coordinator, Honoring Choices Minnesota (612) 362-3703; lbetzold@metrodoctors.com

M Health .............................................................29

Annie Krapek, Assistant Project Coordinator Physician Advocacy Network (612) 362-3715; akrapek@metrodoctors.com Emily Larsen, Marketing & Communications Coord.

(612) 623-2885; elarsen@metrodoctors.com Helen Nelson, Administrative Assistant, Honoring Choices Minnesota (612) 362-3705; hnelson@metrodoctors.com Ellie Parker, Project Coordinator Physician Advocacy Network (612) 362-3706; eparker@metrodoctors.com

Greenwald Wealth Management ..................18 HealthPartners Medical Group .....................35 Lakeview Clinic .................................................34 Medifast Weight Control Centers ................19 MMIC ................................ Outside Back Cover PrairieCare PAL .................................................28 Saint Therese......................................................... 2 Senior LinkAge Line.........................................32 St. Cloud VA Medical Center ............................

Inside Back Cover St. David’s Center .............................................31 Uptown Dermatology & SkinSpa................31

Saint Therese Rehab

Strengthening. Therapeutic. Results.

Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com.

For advertising rates and space reservations, contact: Betsy Pierre 2318 Eastwood Circle Monticello, MN 55362 phone: (763) 295-5420 fax: (763) 295-2550 e-mail: betsy@pierreproductions.com MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Advertisements published in MetroDoctors do not imply endorsement or sponsorship by TCMS. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Andrea Farina at (612) 623-2885.

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March/April 2016

MetroDoctors

The Journal of the Twin Cities Medical Society

CONTENTS VOLUME 18, NO.2 MARCH/APRIL 2016

5

IN THIS ISSUE

Savvy Solutions for an Obesity Epidemic

By Marvin S. Segal, M.D.

6

PRESIDENT’S MESSAGE

Bulk Up It’s Cold Outside

By Carolyn A. McClain, M.D.

7

TCMS IN ACTION

By Sue Schettle, CEO

Page 36

8

STATE OF OBESITY

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The Current State of Obesity

By Julie Myhre, RN, MS and David S. Simmons, MPH

11

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Causes and Comorbidities of Obesity

By Daniel Hurley, M.D.

14

•

Colleague Interview: A Conversation with J. Michael Gonzalez-Campoy, M.D., Ph.D., FACE

17

•

Obesity in Minnesota: Outcomes, Costs and Trends

By Erin Ghere

20

•

SPONSORED CONTENT:

Integrated Health Care Approach Research-Driven Strategies Improve Outcomes for Weight-Loss Surgery

By Daniel B. Leslie, M.D.

Page 14

Page 33

22

•

Treating Obesity: Getting to Know the Weight Loss Medications

By Laurie Kaiser Sund, M.D., FAAFP

25

•

Obesity and its Related Chronic Diseases from a Corporate Perspective

By Nicolaas P. Pronk, Ph.D.

27

•

Preventing Type 2 Diabetes

By Identifying and Addressing Prediabetes

By Kathryn Justesen, M.D.

30

•

Minnesotans for Healthy Kids Coalition— Taking Action for a Healthier Minnesota

By Rachel Callanan

32

Edward P. Ehlinger, M.D., Receives Shotwell Award

33

TCMS Holds 2016 Annual Meeting

34

First a Physician Award Career Opportunities

36

C. Walton Lillehei, M.D.

Page 32 MetroDoctors

LUMINARY OF TWIN CITIES MEDICINE

The Journal of the Twin Cities Medical Society

Obesity in Minnesota. Experts in the field offer their experience, advice and encouragement.

Articles begin on page 8.

March/April 2016

3

Twin Cities Medical Society

Electronic Cigarette Webinars What we know and what to tell patients Free CME Webinars Webinar Overview:

Clear the smoke around e-cigarettes and other new tabacco products!

Participate in the free Physician Advocacy Network webinar series: “Up in Smoke”; a series of three, thirty minute pre-recorded webinars, worth .5 AMA PRA Category 1 Credit(s) each.

Participants will: • • •

Explore the health and public health impact of new tobacco products like e-cigarettes, hookah, flavored cigarillos, and cigars Increase individual awareness of new tobacco product usage rates in Minnesota among adults and youth Learn practical talking points and tips for engaging in meaningful patient conversations to reduce risk associated with these products

Speakers

Pete Dehnel, MD Physician Advocacy Medical Director

Visit our Website to view webinars www.metrodoctors.com

A. ‘Stu’ Hanson, MD Pulmonologist, Park Nicollet, Physician Advocacy Network Champion

To register or view webinars: • • •

Visit http://www.metrodoctors.com/dev/index.php/cme-physician-webinars Click on the webinar(s) you would like to view to register Complete webinar(s) and evaluation(s) for CME credit

IN THIS ISSUE...

Savvy Solutions for an Obesity Epidemic

Dear Readers, This edition of MetroDoctors deals with a condition that essentially all practicing physicians face on a daily basis and that touches virtually every medical specialty and discipline — perhaps more so than any other medical issue.

•

Dr. Daniel Leslie, of M Health, discusses the updated techniques and improved outcomes in Bariatric Surgery, following the pathways historically forged by our U of M surgeons.

•

The often confusing and sometimes controversial area of Weight Loss Medications is addressed by Dr. Laurie Sund including benefits, risks, pros, cons and wise “pearls” that deal with this emerging arrow in our quiver of treatments.

•

Dr. Nicolaas Pronk effectively examines the challenges of this defiant health problem and its secondary disease states from a Corporate Perspective.

•

It’s comforting to realize that type 2 diabetes can actually be prevented! Dr. Kacey Justesen crisply discusses the identification and addressing of the pre-diabetic state.

With Diabetes Alert Day coming up on March 22, useful suggestions for a prediabetes screening event in your clinic are offered.

•

Rachel Callanan describes the Minnesota Healthy Kids Coalition and the successes this diverse collaborative group of organizations has and will realize in the struggle against childhood obesity.

•

Dr. Carolyn McClain, in her President’s Message, nicely relates some personal thoughts about this condition in a whimsical and savvy fashion.

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This edition’s Luminary article features yet another of our medical community’s remarkable physicians, Dr. C. Walton Lillehei.

Some meaningful quotations set the stage: “Epidemic obesity is arguably the gravest public health crisis we face, and inarguably among the least controlled — a crisis in slow motion that has crept up on us over years and even decades.” (Katz) “Obesity affects every aspect of people’s lives — from health to relationships.” (Velezmitchell) “The rise of childhood obesity has placed the health of an entire generation at risk.” (Vilsack) Your editors were able to gather a marvelous array of articles that should add to your knowledge base and bring you up to speed with some of the current thinking on this important topic: • Julie Myhre and David Simmons in The Current State of Obesity lead off by relating factual and statistical information regarding our State and the collaborative activities presently underway to combat this enemy.

•

The Causes and Comorbidities of Obesity are efficiently covered by Dr. Daniel Hurley who speaks of the serious consequences of adiposity and the multifactorial elements at play in its etiologies.

•

The erudite responses by Dr. Gonzalez-Campoy to a gamut of tough questions posed by the editors in our Colleague Interview provide us with expert opinions regarding approaches to patient care based upon science and experience.

•

In Minnesota Obesity: Outcomes, Costs and Trends, Erin Ghere nicely adds some complementary information to the readers’ data base, to even better position us to combat this health-robbing condition.

By Marvin S. Segal, M.D. Member, MetroDoctors Editorial Board

MetroDoctors

The Journal of the Twin Cities Medical Society

Go right ahead; feel free to begin turning our pages. You’ll have some interesting reading.

Sincerely, Your MetroDoctors Editors

March/April 2016

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President’s Message

Bulk Up It’s Cold Outside CAROLYN A. McCLAIN, M.D.

TURNS OUT, MINNESOTA IS GAINING WEIGHT. As a population, we were holding steady on the scale for a few years at 25% of our total population classified as obese but, like the rest of the country, we couldn’t resist that last cupcake, and in 2015 27.6% of Minnesotans were obese. That puts us at number 15 in “America’s Health Rankings” reported by the United Health Foundation. (#1 is the thinnest state.) I get Hawaiians being thin; after all if I had to wear a swim suit the majority of the time I would find a way to hold back on that second donut. Plus, cut us some slack, Minnesota is cold! In 2014 while we were packing on the pounds there were several days where it was colder in the Twin Cities than Antarctica. If it is any consolation, we are not gaining weight alone. 57.6% of our dogs and cats are obese, 19% of horses and the statistics on domesticated reptiles are abysmal. Seriously, I understand overfeeding our dogs, but our snakes?

As physicians, we are all well aware of the toll obesity takes on our patients. Estimates range from 150 billion to 200 billion additional health care dollars spent per year on obesity-related health care issues alone. For our part, physicians have done a good job of getting the message out; a healthy weight requires a healthy diet and exercise. Our patients are listening. Americans spend 40 billion dollars a year on weight loss programs and products. We want to lose weight. But we’re not.

If this was primarily a physiologic problem, then the prescription of diet and exercise we regularly prescribe would work. But there is so much more to it. As far as exercise goes, we live in a virtual world.

Most of us are entertained by movies and television; we work on computer screens and play games on our smart devices. United Health Foundation reported that 20% of Minnesotan’s have not even taken a walk in the past month.

Furthermore, our environment is primed for eating. By the time our children are toddlers, they no longer eat because they’re hungry. They are trained to eat based on social cues. My daughter learned early on that crying on a plane got her a pack of goldfish crackers and cheerios. As we grow up, food is a fundamental part of how we experience the world. We leave cookies for Santa Claus, eat jelly beans at Easter, and on Halloween…enough said. Socially, we have dinner with friends, eat popcorn at a movie, or bring casseroles to our sick neighbors. Food helps create our social bonds. As physicians, helping our patients lose weight is not just a prescription of diet and exercise, it is a battle against all aspects of our society.

So what can we do? Looking at the data from the American Health Rankings there are some simple things we can tell our patients to make Minnesota healthier. Minnesotan’s rank low on vegetable consumption. Let’s change that. Instead of telling our patients to eat less, we could tell them to eat more vegetables. Plus, evidence shows that the less you like the food you eat, the less you eat overall. (I’m not a big vegetable fan.) We can give a clear message that any exercise is better than none — even 10 minutes a day. We can encourage our patients to change their lifestyles as a family, because without changing our environmental cues around eating even successful weight loss will not be maintained. Finally, we need to remember that what we say to patients about their weight matters. At my last physical with my primary, she discussed my weight honestly with empathy and gave me concrete suggestions on what to do next. As a physician, she could talk to me about my weight in a way that my husband or friends can’t without fear of reprisals. Sometimes, it is only as a patient that you can hear the truth.

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March/April 2016

MetroDoctors

The Journal of the Twin Cities Medical Society

TCMS IN ACTION SUE A. SCHETTLE, CEO

TCMS Represented on MN Cancer Alliance

Sue Schettle, CEO of TCMS, was elected to serve her first term on the MN Cancer Alliance Steering Committee. The Steering Committee provides leadership and strategic and policy direction for the Alliance.

Its members — all volunteers — are responsible for implementing Cancer Plan Minnesota. The mission of MCA is to reduce the burden of cancer for all people living in Minnesota by working together to promote the goals of Cancer Plan Minnesota.

New Workgroups Forming

As we begin to put the pieces together to support the implementation of our strategic plan new opportunities exist for TCMS members to become involved. In early 2016 a taskforce will be formed to tackle issues related to obesity. We are already working on a community-based pre-diabetes screening initiative (see article on page 27) and are optimistic that we’ll work with the Minneapolis Health Department on ReThink Your Drink, sugar sweetened beverages, and other issues.

If you have an interest in joining the workgroup please email nbauer@ metrodoctors.com or call TCMS at (612) 623-2885.

TCMS Physician Advocacy Network

2015 was a very productive year for the physician advocacy activities of TCMS. Our Physician Advocacy MetroDoctors

Network (PAN) works to engage, educate and empower physicians to advance policy primarily at the city and county level. Ellie Parker, MPH has led efforts to expand clean indoor air ordinances to include e-cigs and other tobacco products. She created a toolkit of resources for physicians to use including the most up-to-date information. In 2015 she partnered with other county medical societies across the state to educate nearly 400 physicians on what we know about e-cigs as well as advancing policies at the city and county level. In addition, we also educated over 250 people who attended the MN Lung Association’s Lung Expo about e-cigs. We plan to use the PAN framework to engage physicians on other issues that TCMS has prioritized.

Welcome to the newest TCMS staff member. Annie Krapek joins Ellie Parker as an Assistant Project Coordinator for the PAN. Honoring Choices MN

The start of 2016 kicked off the Greater Minnesota Advance Care Planning project for HCM. Staff is currently engaging in conversations with leadership from hospitals outside the metro area who have expressed an interest in introducing or expanding advance care planning in their region.

It is our goal to support two or three regions in this endeavor in 2016.

The Journal of the Twin Cities Medical Society

Outgoing Leaders

Our thanks to outgoing TCMS Board members Roger Kathol, M.D., Stuart Cox, M.D. and Doug Hanson for your service to TCMS. We know that serving as a volunteer on the TCMS Board of Directors is a time commitment and we thank you for your commitment and leadership!

Our appreciation is also extended to John Diehl, JD, Kenneth Britton, M.D., Martin Lipschultz, M.D. and medical student Chris Perdoni who all served on the TCMS Foundation Board of Directors.

TCMS Partners with U of M Medical School

The U of M has approached TCMS and asked that we partner with them in offering first year medical students the opportunity to work up to 100 hours a year on our various public health initiatives through their Public Health and Health Policy pilot project. Of course we jumped at the chance and are eager to get the early volunteers we have received thus far engaged in our work. At the end of their project student(s) must present their experience in the form of a poster to peers and U of M faculty in the spring of Year 2. Win-win.

March/April 2016

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State of Obesity

The Current State of Obesity

A

s a risk factor associated with poorer mental health outcomes, reduced quality of life, and chronic diseases including diabetes, heart disease, stroke and some types of cancer, obesity is a major health concern.(1) Clinical data from the National Health and Nutrition Examination Survey (NHANES) indicate that the obesity rate has been relatively stable from 2003 to 2012,(2) and Minnesota obesity rates from the Behavioral Risk Factor Surveillance System (BRFSS) have also remained stable since 2007.(3) Although the 2014 rate of 27.6% showed an increase over 2013, it falls within the range of rates seen from 2007 to 2014 and is below the U.S. median rate of 29.6%. Rates from future years will show whether the 2014 rate indicates a change in trend for Minnesota.

While modeling of obesity rates suggest that obesity will plateau at some point,(4) and Minnesota rates have been stable, obesity is of critical importance.

Further, the national burden is shared unequally in terms of race/ethnicity, gender, and age.(2) This inequity is evident in Minnesota.

The Burden of Obesity is Greater for Some Minnesotans Than for Others

The combined Minnesota BRFSS data from the years 2012 to 2014(3) created a data set with the statistical power to make comparisons of obesity rate by race and ethnicity. These comparisons showed that African Americans, Hispanics, and American Indians have statistically higher

By Julie Myhre, RN, MS and David S. Simmons, MPH

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March/April 2016

obesity rates than do non-Hispanic whites.

In contrast, the Minnesota Asian American population has the lowest obesity rate of all racial/ethnic groups in the state.

The Obesity Rate for Women is Increasing

In Minnesota, the obesity rate for men has been higher than for women, but the rate for women has increased annually from 2011-2014 while the rate for men has remained relatively unchanged during this period.(3) National clinical data indicate that the obesity rate for women has surpassed men.(2) While this is not the case in Minnesota at present, the increase in rates from 2012 to 2014 is important to monitor to support women’s health.

Obesity Rates Also Show Disparities Based on Age, Income and Education Level

In addition to race/ethnicity and gender, the age, income, and education level of

Minnesotans provide further insights into the state obesity burden.

For instance, the obesity rate for Minnesotans increases as age increases. The rates in the age group 35-44, 45-54, and 55-64 were 29.8%, 31.5%, and 32.9%, respectively, compared to the state rate of 27.6%. Rates in the age groups 18-24 and 25-34 were below the state rate at 16.2% and 23.7%.

The obesity rate among the lowestpaid Minnesotans has increased in each year from 2011-2014. The obesity rate for Minnesotans paid less than $15,000 a year was 23.3% in 2011 and 34.0% in 2014. The 2014 obesity rates based on education level show a dramatic difference between Minnesotans with a college education at 21.9% and those having less than a high school diploma, having a high school diploma or GED, and some college with rates of 31.6%, 29.3%, and 30.3%, respectively.

MetroDoctors

The Journal of the Twin Cities Medical Society

SHIP: One Way Minnesota is Helping Create Healthier Communities

In 2008, Minnesota lawmakers passed a groundbreaking health reform law. A key component of that reform was to create the Statewide Health Improvement Program (SHIP), which is designed to prevent chronic diseases by increasing opportunities for healthy eating and physical activity and reducing tobacco use and secondhand smoke exposure. Other health reform initiatives that contribute to improving the health and quality of life for Minnesotans include Health Care

Homes and more recently the Accountable Communities for Health funded through the State Innovation Model Grant.

The Minnesota Department of Health (MDH) partners with the state’s Community Health Boards (which is the local governance structure for public health) and Tribal Governments on SHIP. Thanks to SHIP, communities are building their capacity to improve health.

Working in partnership with MDH, communities choose strategies based on the latest science and focused on changing the policies, systems and environments in schools, communities, workplaces and

health care settings. Communities work on strategies that align with local needs to address chronic disease.

SHIP, now in its fourth biennial funding cycle, is supported by $35 million in state funding. Efforts cover all 87 counties, the cities of Minneapolis, Bloomington, Edina and Richfield and 10 Tribal Nations.

Each grantee convenes a Community Leadership Team that supports local SHIP work by assessing their communities, identifying needs and developing plans to collectively address those needs. Members represent schools, businesses, housing owners/managers, farmers, community groups, senior organizations, hospitals, clinics, planning entities, Chambers of Commerce, faith communities, and more.

A key area of collaboration for SHIP is with Minnesota’s medical community.

SHIP grantees work across the state with interested clinics to support their obesity prevention efforts. SHIP provides technical assistance and training with clinics on several levels, including helping clinics: • establish systems to screen patients for obesity; • provide counseling and referrals to evidence-based programs on weight and chronic disease management; • establish systems for follow up from evidence-based programs to clinics.

Technical assistance is also available to increase local access to evidencebased programs such as the National Diabetes Prevention Program (NDPP), Chronic Disease Self-Management Programs (CDSMP) and pediatric weight management programs.

NDPP can help people with prediabetes make lifestyle changes that can cut their risk of developing type 2 diabetes in half. The program is based on a CDC led research study that showed that making modest behavior changes, like eating healthier and adding physical activity, helped participants lose 5 to 7% of their body weight.

To support progress made through the clinical setting, SHIP also collaborates (Continued on page 10)

MetroDoctors

The Journal of the Twin Cities Medical Society

March/April 2016

9

State of Obesity The Current State of Obesity (Continued from page 9)

on efforts to expand opportunities for physical activity and healthier eating in communities, schools and workplaces.

Thanks to SHIP, more communities across Minnesota are increasing access to local produce at farmers markets; serving healthier foods and increasing physical activity opportunities at schools and child care facilities; making biking and walking easier; working with employers to improve workers’ health and productivity; and on and on.

More Opportunities for Collaboration

In 2014, MDH received Centers for Disease Control & Prevention funding for the Community Wellness Grant (CWG), which builds on current work to prevent and better manage obesity, diabetes, heart disease and stroke, while focusing on reducing health disparities.

CWG is funding efforts with four grantees

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across the state; one component of CWG is improving the quality of health care delivery.

Another statewide effort is to have employers, and public and private insurers offer the NDPP as a covered benefit, another effort to broaden local access to evidence-based programs. Since April 2014, the State of Minnesota has offered “Prevent,” which is based on NDPP, as a benefit for employees and their adult dependents. As of December 2015, more than 4,400 people have signed up and have collectively lost 15 tons of weight.

With efforts like those in place, opportunities for future collaboration between MDH and the medical community point the way toward reducing the burden of obesity in Minnesota.

Julie Myhre, RN, MS, serves as the director of the Office of Statewide Health Improvement Initiatives (OSHII) at the Minnesota Department of Health (MDH). OSHII’s mission is to improve the health of all people

in Minnesota through local, state and tribal partnerships to create community-level changes that promote and support active living and healthy eating and prevent commercial tobacco use. One of the key grants within OSHII is the Statewide Health Improvement Program (SHIP), which addresses obesity and commercial tobacco use through policy, systems and environmental changes.

Julie has a master of science degree in public health nursing.

David S. Simmons, MPH joined the Office of Statewide Health Improvement Initiatives (OSHII) at the Minnesota Department of Health (MDH) in June 2010. In his role as Senior Epidemiologist, David monitors surveillance data related to obesity, physical activity and nutrition in accordance with the Statewide Health Improvement Program (SHIP) and the mission of OSHII. David received his MPH in Epidemiology and BS in Biology from the University of Minnesota.

References available upon request.

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March/April 2016

Bruce Birkeland / 612.925.8405 / BirkelandBurnet.com

MetroDoctors

BURNET

The Journal of the Twin Cities Medical Society

Causes and Comorbidities of Obesity

Article Highlights

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There is a significant genetic component to obesity.  There is a strong association between total energy expenditure (TEE), resting energy expenditure, and fat-free mass (FFM).

Differences in FFM account for a large percentage of TEE variance among individuals.

The presence of being overweight or obese significantly increases the risk of pre-diabetes, diabetes, hypertension, hyperlipidemia, coronary heart disease, and certain types of cancers.  Obesity, diabetes, and depression often co-exist.

Marked weight gain and obesity from endocrine gland and hormone disorders are uncommon.  Hypothyroidism may cause a very modest increase in weight due to slowing of metabolic activity.

It is important to be aware that commonly prescribed drugs can cause weight gain, to include oral diabetes agents, insulin, antidepressants and other mood altering drugs.

Health Consequences of Weight Gain

The prevalence of excess adiposity in the U.S. is at unprecedented levels, with approximately two-thirds of adults overweight and one-third obese. These estimates are based on body mass index (BMI, kg/m2).

However, health risks are high in the presence of both obesity (>30 kg/m2) and an overweight status (25-29.9 kg/m2) when the waist circumference (WC) is increased,

Endocrine Causes of Weight Gain

due to visceral/abdominal fat being more metabolically active than subcutaneous fat. Adipose tissue is an active endocrine tissue, secreting a variety of hormones, to include leptin and adiponectin. Fat accumulation increases inflammatory cytokines (interleukin, tissue necrosis factor) and leads to tissue inflammation and insulin resistance. The impact of excess weight is significant for both individual and population-based health-care disease burden and costs. Cardio-metabolic conditions related to obesity include pre-diabetes, type 2 diabetes (T2DM), hyperlipidemia, hypertension, and coronary heart disease.

The risk of developing T2DM and hypertension increases with increasing BMI and WC. BMI and WC are each independently and strongly associated with T2DM in all adults. In addition, secondary increases in body weight and tissue inflammation contribute to osteoarthritis, obstructive sleep apnea, reactive airway disease, polycystic ovary disease, decreased fertility, and certain cancer types (breast, ovary, endometrium, colon, prostate, etc.)

Weight gain is inevitably caused by consuming excess calories relative to energy expended, but the etiology of obesity is highly complex and includes genetic, physiologic, environmental, and psychosocial factors. Although only a small number of single genetic abnormalities have been discovered that are related to obesity, research is investigating the influence of behavioral, environmental, metabolic, and endocrine factors on genetic expression in patients with obesity. Genetic factors have been reported to explain a large component of BMI variability in family studies, to include twin studies (50-90% of BMI variance) and parent-offspring and sibling correlations (20-80% of BMI variance).

Longitudinal studies have identified both parental obesity and childhood obesity as strong predictors of obesity in adulthood.

The influence of having one parent with obesity throughout an individual’s childhood/adolescence increases that person’s risk of obesity in adulthood by 2 to 3-fold, with a substantially higher risk if both parents have obesity.

Low energy expenditure is one factor that may promote weight gain. Approximately 70% of total energy expenditure (TEE) is utilized for metabolic cellular and organ basal, or resting, energy expenditure (REE) needs. Another 10% of TEE is dissipated through the thermic effects of food digestion, and the remaining energy expenditure is from activities of daily living and exercise. There is a strong relationship between TEE, REE, and fat-free mass (FFM). Differences in

By Daniel Hurley, M.D.

(Continued on page 12)

MetroDoctors

March/April 2016

The Journal of the Twin Cities Medical Society

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State of Obesity Causes and Comorbidities of Obesity (Continued from page 11)

FFM account for a large percentage of TEE variance among individuals, and 100 kcal below the expected 24-hour TEE corresponds to 0.2 kg/year weight gain. Thus, an individual’s REE may play a small role in weight change in the short-term, but a potentially significant role for weight gain over that person’s lifetime. Thyroid hormone interacts closely with the adrenergic nervous system to generate heat in response to cold, termed adaptive thermogenesis. This process stimulates mitochondrial biogenesis and up-regulation of fatty acid oxidation. Patients with hypothyroidism may gain weight due to slowing of metabolic activity, but the weight gain is modest and marked gain is uncommon. In general, subclinical hypothyroidism (TSH 5-10 mIU/L) has been variably associated with increased baseline weight in adults compared to euthyroid individuals, but without weight gain over time. Weight loss has been reported up to 3.8 kg following onset of thyroid hormone therapy, but only about half of patients lose weight.

In addition, there is no data to support that properly treated hypothyroidism contributes to weight gain. Conversely, it has been suggested that abnormalities in thyroid function may be secondary to excess adiposity. Two studies have shown that up to 10% of patients seeking bariatric surgery have TSH elevation consistent with subclinical hypothyroidism (defined as elevated TSH with normal free thyroxine values). After surgery, >87% of patients in one study and 100% in another had TSH values return to normal. TSH levels correlated positively with BMI, and the high rate of spontaneous TSH recovery suggests that follow-up alone is sufficient in the majority of patients undergoing bariatric surgery who have subclinical hypothyroidism.

There is growing interest in the role that physiological and behavioral stress play in weight gain, as high stress levels have been linked to weight gain and appear to inhibit weight loss. When experiencing the same degree of stress, persons with a high BMI gain more weight than those with a lower BMI. Stress-related eating is also significantly associated with obesity 12

March/April 2016

in women. The interactions between the brain and endocrine hormones may play a role in activating this stress response toward reward seeking and appetite regulation. The effect of cortisol ‘stress hormone’ on visceral fat can be explained by the induction of 11-beta-hydroxysteroid dehydrogenase (11ß-HSD) and enhanced lipogenic activity. Patients with obesity and the Metabolic syndrome have reportedly higher visceral fat expression of 11ß-HSD1, higher fat expression of the glucocorticoid receptor, and increased Hypothalamic-Pituitary-Adrenal axis activity compared to patients with obesity but without the Metabolic syndrome. Of note, weight loss after bariatric surgery results in decreased cortisol levels and lower expression of adipose tissue 11ß-HSD1, when compared to control subjects with normal weight.

Commonly Used Drugs as Causes of Weight Gain

Many medications commonly prescribed for the treatment of T2DM, hypertension, and depression may be associated with weight gain (Tables 1 and 2). Beta-blockers may cause weight gain. Weight-neutral

anti-hypertension agents include angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and calcium channel blockers. Insulin administration prescribed for both conventional and intensive insulin therapy can cause weight gain. Patients receiving insulin gain approximately 1 to 3 kg more weight than those receiving oral diabetes agents. In the Diabetes Control and Complications Trial, a mean increase in weight of 5.1 kg versus 2.4 kg was seen in the intensive versus conventional treatment groups. Sulfonylureas and thiazolidinediones are associated with weight gain, whereas metformin use in the Diabetes Prevention Program resulted in a significant 2 kg weight loss in patients with impaired glucose tolerance. Other oral diabetes agents are weight-neutral or associated with small declines in weight (Table 1). Injectable glucagon-like peptide-1 receptor agonists have been shown to provide improved glycemic control, blood pressure reduction, and significant weight loss. Thus, diabetes therapy should include not only instruction in healthy eating and regular activity, but also medications that are safe, effective, and weight neutral or associated with weight loss.

Table 1: The potential effects of diabetes-related drugs on weight change Drug Class

Drug Agent(s)

Weight Change

Amylin analogs

pramlintide

↓↓

Biguanides

metformin

↓

albiglutide, dulaglutide, exenatide, liraglutide

↓↓

canagliflozin, dapagliflozin, empagliflozin

↓

acarbose, miglitol

↔

colesevelam

↔

alogliptin, linagliptin, saxagliptin, sitagliptin

↔

bromocriptine

↔

nateglinide, repaglinide

↑

glimepiride, glipizide, glyburide

↑↑

aspart, detemir, glargine, glulisine, lispro, NPH, regular

↑↑

pioglitazone, rosiglitazone

↑↑

GLP-1 receptor agonists SGLT-2 inhibitors α-Glucosidase inhibitors Bile acid sequestrants DPP-4 inhibitors Dopamine-2 agonists Glinides Sulfonylureas Insulins Thiazolidinediones

Garber AJ, et al. Endocr Pract 2013;19:536-557 and Domecq JP, et al. J Clin Endocrinol Metab 2015;100:363-370.

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Table 2: The potential effects of CNS psychoactive drugs on weight change Drug Class

Related to Weight Gain

Related to Weight Neutrality or Loss

Antidepressants

mirtazapine, TCA’s, SSRI’s (paroxetine)

bupropion, venlafaxine, SSRI’s (fluoxetine, sertraline)

Antipsycholtics

clozapine, olanzapine, quetiapine, risperidone, thioridazine

aripipazole, ziiprasidone

Antiepileptics

gabapentin, valporate

lamotrigine, topiramate, zonisamide

Others

lithium

CNS, central nervous system. SSRI’s, selective serotonin reuptake inhibitors. TCA’s, tricyclic antidepressants (i.e., amitriptyline, clomipramine, doxepin, imipramine).

Tricyclic antidepressants are all associated with significant weight gain (Table 2). In contrast, not all selective serotonin receptor inhibitor’s (SSRI) have been associated with weight gain. In a randomized study of patients receiving SSRI’s, a significant increase in weight occurred only with paroxetine, and not with sertraline or fluoxetine. Antipsychotics’s can cause significant weight gain (Table 2), reportedly between 0.8 and 4.4 kg. Antagonism of histamine H1 receptors has been suggested as a main cause of antipsychotic-induced obesity. During long-term treatment, hypothalamic H1 receptor antagonism can reduce thermogenesis, and contribute to fat accumulation by decreasing lipolysis and increasing lipogenesis. Central opioidergic neurotransmission may be implicated in the metabolic disturbance with olanzapine therapy. In a randomized, double-blind study the addition of naltrexone to olanzapine did not result in BMI differences, but subjects taking naltrexone plus olanzapine had significant beneficial changes in fat, FFM, and insulin resistance. Antipsychotics also seem to induce a hypo-metabolic state. These findings support a centrally mediated imbalance with mood altering drugs that lead to increased weight and adverse metabolic outcomes.

Progestin-only contraceptives are long-acting and cost-effective, but concerns about weight gain can deter their use. In a systematic review, women using progestin-only contraceptives did not differ in weight from their comparison contraceptive groups. However, three studies MetroDoctors

showed significant increases for progestinonly contraceptives compared to women not using hormone contraception.

Conclusion

Although endocrine disorders may be associated with modest weight gain, as seen in subclinical hypothyroidism or subclinical hypercortisolism, they are rarely the cause for marked or continued weight gain. A more typical scenario is polypharmacy

The Journal of the Twin Cities Medical Society

with drugs that may cause weight gain when used to treat T2DM, hypertension, and depression. A focus solely on modifying behaviors for healthy eating and increased activity may have had limited success for weight loss if physicians and health care providers are not aware of the genetic variability between individuals in energy metabolism, and the effect that commonly prescribed medications have on weight change.

Daniel L. Hurley, M.D. is a Consultant in the Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN and Assistant Professor of Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, and a Fellow in the American Association of Clinical Endocrinologists. His clinical interests have included skeletal bone health and osteoporosis, nutrition in health and disease, and communication in healthcare. Dr. Hurley can be reached at (507) 284-4738; hurley.daniel@mayo. edu.

References available upon request.

March/April 2016

13

State of Obesity

Colleague Interview: A Conversation with J. Michael Gonzalez-Campoy, M.D., Ph.D., FACE

J

Michael Gonzalez-Campoy, M.D. is the Medical Director and Chief Executive Officer of Minnesota Center for Obesity, Metabolism and Endocrinology (MNCOME). He received his medical degree and Ph.D. at Mayo Medical School and Mayo Graduate School, Rochester, MN. He completed an Internal Medicine residency also at Mayo Graduate School followed by a Diabetes, Endocrinology and Metabolism fellowship at the University of Minnesota. He has been in private practice since 1997.

Dr. Gonzalez-Campoy is an Adjunct Assistant Professor of Medicine at the University of Minnesota Medical School. He is a sought after local, national and international lecturer and has chaired or been an invited speaker for several national meetings on obesity and adiposopathy.

The dietary approach to obesity has largely failed.

Some progress has been made via public health, labeling requirements and ingredient prohibition.

Where do you see the most progress in the future?

In 2013 I co-chaired the writing team that published the American Association of Clinical Endocrinologists and The Obesity Society’s healthy eating clinical practice guideline.(1) In this document we formally call for us to abandon the terms “diet” and “exercise.” We agree that dieting alone does not work. Instead we want patients to learn meal planning, healthy eating, and what constitutes good nutrition. This then becomes one of the cornerstones of good health. Instead of what not to eat, patients should learn what to eat. The single biggest concept in healthy eating for overweight and obesity is caloric restriction over time. And physical activity that is built into a daily routine, which is realistic, achievable, sustainable, and incremental over time, is a better approach to caloric expenditure. Progress in the future will come from the application of chronic disease management principles to overweight and obesity.(2)

Does one inherit a “fat gene”?

Obesity is a genetic disease. Although there are many models of monogenic obesity, and they have helped us to understand the biology behind the regulation of energy balance and fat stores, the

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vast majority of obesity is polygenic. There is not a single “fat gene.” How the genes express themselves is dependent on the obesogenic environment we live in — therefore both genetics and environment play major roles in the epidemic of obesity.

What is your opinion about the regulation of “foods”; “big gulp” sugar drinks, fried foods, etc.

At its core, although feeding is a behavior, it is really a survival mechanism. One has to be extremely ill to lose the drive to feed.

I do not think that regulation of what is sold is the best approach to the epidemic of obesity. Rather, I think education is best. Once food is ingested, it really does not matter what it looked like, how it smelled, or how it tasted. It all becomes protein, carbohydrate and fat. So it is the total caloric load, compared to the caloric expenditure over the same time frame, that really determines if there will be an increase in adipose tissue mass. What we eat, how much we eat, when we eat, where we eat, and who we eat with, are all learned behaviors. It is never too late to relearn a healthier approach to nutrition. The hedonistic aspects of food intake, including sugar activation of the reward center, do contribute to excess caloric loads and are now the target of pharmacotherapy (ie bupropion-naltrexone).

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What are your thoughts on the genetic manipulation of the food chain — upside and potential downside?

When Malthus published his theories about food supplies and population dynamics in 1798, he made the assumption that the production of food would be a constant. Human ingenuity has proven these assumptions wrong. Genetic manipulation has allowed for better crop yields, and this has provided for a growing world population. Mechanized agriculture paved the way, but improved food distribution, improved food conservation, and certainly genetic manipulation have all ensured that we have a steady food supply. Genetic manipulation has very little downside, in my opinion.

Are there unique obesity implications of various demographic and/or cultural disparities?

Overweight and obesity affect every racial and ethnic group.

There is a higher burden of disease in populations descending from African and Asian gene pools, including indigenous American populations. This translates into higher prevalences of metabolic diseases including diabetes mellitus and premature cardiovascular disease in this population, compared to a white caucasian population.

How important a role does exercise play in a standard weight loss regimen?

If I ask a patient with obesity to exercise, that advice carries the potential for real harm. The higher the excess weight, the higher the probability of distorted biomechanical dynamics, and the higher the probability of orthopedic injury. Additionally, there will be patients with hidden cardiovascular disease where exercise may trigger angina or myocardial infarction. For these reasons we recommend the term “physical activity” in lieu of “exercise.”

Caloric expenditure is achieved by moving body mass over distance or against gravity. Nothing says it must happen all at once, or that it must happen fast. The best advice for a patient with overweight or obesity is to achieve incremental physical activity in small, frequent units. For example, if one goes up and down a flight of stairs at the beginning of every commercial break while watching TV in the evening, and the TV is on for two hours, then every evening, before going to bed, one will have climbed a 20 story tall building. Since caloric expenditure is half of the energy balance equation, it must be accomplished over time for long-term success in the management of overweight and obesity. Once the weight is down, a focus on cardiovascular fitness through incremental physical activity becomes a reasonable goal.

How close are we to endocrinological or micro-biome therapy for obesity?

Endocrinological therapy for obesity is already a reality. A concrete example of this is the glucagon-like intestinal peptide–1 (GLP-1) MetroDoctors

The Journal of the Twin Cities Medical Society

analogues, which not only return insulin secretion toward normal in people with type 2 diabetes mellitus, but also lead to weight loss through several distinct mechanisms of action.

The intestinal flora of the gut is now known to regulate metabolism, energy balance, and fat stores. In the not too distant future the gut micro-biome will be a target for intervention in the treatment of overweight and obesity.

What are the major obstacles to obesity prevention?

The major obstacles to obesity prevention are: 1) financial disincentives for medical practices to provide nutrition education and physical activity counseling; 2) the lack of effective coordination across venues where prevention measures should be implemented (i.e. schools, homes, medical practices) and public health institutions; 3) increasing screen times (TV, computers, hand-held devices, video games); and 4) the tremendous marketing of high calorie foods and mechanized devices that discourage physical activity (i.e. motor vehicles and power tools). Other obstacles include the outdated but still prevalent belief that overweight and obesity are not a disease,(3) the cultural bias that excess weight is healthy in some ethnic groups such as Mexican Americans, and the reluctance to use FDA-approved medications for the treatment of obesity early on, to prevent disease progression (i.e. lorcaserin, liraglutide, bupropion-naltrexone, orlistat, and phenterminetopiramate, in addition to older generics).

Describe the long-term effects of morbid obesity, and what are the effects should long-term weight loss succeed?

Overweight and obesity may affect every single organ system.

Because there is tremendous biological variability, every patient should have their individual health risk stratified, and re-stratified over time. The concept of a “healthy person with obesity,” which refers to people with obesity but no hyperglycemia, hyperlipidemia, or hypertension, has been introduced into the medical literature. “Healthy with obesity” is not a permanent state. And in fact, most of these patients do have physical complications of overweight and obesity. Adiposopathy, or “sick fat” is a core defect that leads to the metabolic complications of obesity.(4-6) Successful weight loss, however achieved, significantly decreases the burden of disease. As little as 5 to 10% body weight loss is documented to improve on comorbid disease.(7-10)

Please compare various surgical options: short- and long-term potential complications and relative effectiveness.

This question merits a review article in and of itself.(11-13) Bariatric surgery has a role to play for patients who have a high burden of disease, or for whom the medical management of obesity has not (Continued on page 16)

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15

State of Obesity Colleague Interview (Continued from page 15)

been successful. Without a doubt there is benefit in the weight loss achieved with bariatric surgery. And with bariatric surgery weight loss is usually faster than structuring a life-long medical weight management program. Yet, it should be made clear to every patient that surgery or no surgery, they will have overweight and obesity for life. Weight regain is very likely after weight loss surgery, and the implementation of a life-long medical weight management program should take place anyway.

The success of bariatric surgery in reversing metabolic diseases is exemplified by diabetes mellitus. With bilio-pancreatic diversion, Roux-en-Y gastric bypass and laparoscopic adjustable gastric band, there is a 95, 80, and 57% remission of diabetes, respectively. This is associated with a 73, 63, and 49% excess BMI loss, respectively.

Following laparoscopic adjustable gastric band, sleeve gastrectomy, Roux-en-Y gastric bypass, and bilio-pancreatic diversion, with over 57,000 consecutive procedures reported in the US Bariatric Outcomes Longitudinal Database (BOLD), the incidence of one or more complications at one year of follow-up were 4.6, 10.8, 14.9, and 25.7% respectively.(14) In the long term, malabsorptive bariatric surgery may lead to the development of nutritional deficiencies including those of iron, thiamine, vitamin B12, folate, calcium, vitamin D, protein, fat-soluble vitamins and essential fatty acids. Malabsorptive surgery also leads to loss of bone mineral density.

The benefit and risk of each bariatric surgery procedure should be considered in light of reductions in mortality and morbidity, and improvements in quality of life and productivity.

On this subject, the FDA has now approved intragastric balloon placement and vagal intermittent blockade to treat obesity.

(15, 16) In the future there will be intraluminal sleeves that can achieve malabsorption of calories without anatomical disruption.

Are there any non-surgical approaches to obesity that reliably succeed?

The application of the model of chronic disease management that we use for chronic diseases such as diabetes mellitus, dyslipidemia, hypertension, asthma, congestive heart failure, AIDS, depression, and epilepsy, to the management of overweight and obesity, is reliably successful.(2, 7) In this model there is a focus on meal planning and healthy eating, and increased physical activity counseling. There is also the institution of monotherapy for weight management, and the inception of combination therapy if monotherapy is not enough.(2, 9, 10) The FDA has approved several medications for the long-term treatment of obesity, each of which has a distinct mechanism of action. The labeling for each agent, per FDA mandate, specifically states that none of these individual drugs has been studied in combination with any others. However, combination therapy 16

March/April 2016

will become the standard of care, and it is already the standard of practice in bariatric medicine practices. Of note, two of the new medications approved for the treatment of overweight and obesity are already combinations of two agents.

The creation of the American Board of Obesity Medicine (ABOM), and the certification examination in obesity medicine (an effort led by Dr. Robert Kuchner of Chicago), has already led to the presence of many bariatric medicine practices across the country. The attitude that overweight and obesity are a personal flaw, due to a lack of character and will power, which is still prevalent in medicine, will give way to the knowledge that this is a biological disease. When we all agree that overweight and obesity warrant a medical intervention, the non-surgical approaches to this chronic disease will be reliably successful.

There are a multitude of commercial weight loss programs (e.g. Weight Watchers, Jenny Craig, Slim-Fast, Nutrisystem, Optifast, etc.). Are there any that stand out as being particularly effective over the long term?

Any commercial program will help patients adhere to a lower caloric intake. Each has the ability to help in the short term, and each can help prevent weight regain in the long term. I do not endorse any of these products, and would rather teach each patient and their family the concepts behind meal planning, good nutrition and healthy eating.

Are there any legislative initiatives (local or otherwise) that might prove helpful?

The federal government did not include obesity as a disease when Medicare was created. To date, federal programs do not cover medical nutrition therapy, pharmacotherapy or medical care for overweight and obesity. This must be changed through the passage of laws that allow for coverage of obesity care. Bariatric surgery and nutrition counseling in primary care clinics only, are the only covered obesity treatments to date.

In Minnesota it is still against the law for the state to pay for obesity medications. The Minnesota Medical Association adopted a resolution to lobby for the removal of language in Minnesota Statutes, Chapter 256B, Subd. 13d, Drug Formulary, which currently specifically excludes payments for medications to treat obesity. Sadly, to my knowledge, the MMA has never acted on this. Removal of this outdated statute would allow thousands of Minnesotans access to the medical care they need, and stands to decrease the economic burden to the state from expenditures on obesity complications.

References available upon request.

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Obesity in Minnesota: Outcomes, Costs and Trends

O

besity is a critical public health issue in Minnesota and nationally. Twenty five years ago, 15%1 of Minnesota adults were obese; today it’s nearly 28%. And while Minnesota is generally considered one of the healthiest states in the nation,2 our obesity rate continues to rise.3 Overweight or obese adults are at higher risk for a range of chronic diseases, including diabetes, hypertension and depression, as well as some forms of cancer.

They are also more likely to develop conditions that negatively affect their quality of life, such as osteoarthritis and physical disabilities.

Children who are overweight are less likely to reach a healthy adult weight, putting them at a higher risk for these same conditions. Additionally, a recent report by the National Center for Health Statistics demonstrated that the toll obesity takes does not wait until adulthood, as one in five youth ages 6 to 19 already had high total cholesterol.4 The financial burden of obesity — both in actual health care costs and decreased productivity due to obesity-related health conditions — is enormous. In 2005, the United States spent $190 billion on obesity-related health expenses and the amount has only grown since that time.5 Childhood obesity alone is estimated to cost $14 billion annually in direct health expenses.6 And the Minnesota Department of Health (MDH) notes that the financial burden of obesity in Minnesota was $2.8 billion in 2006 — more than double what it was just two years earlier.7 The personal and economic costs underscore why it’s critical to understand

By Erin Ghere MetroDoctors

where obesity is most prevalent in our communities so we can effectively target interventions.

Obesity Among Adults in Minnesota

Obesity in Minnesota tends to be more prevalent among men, Hispanics and those nearing traditional retirement age.

In Minnesota during 2014: • Men were about 2% more likely to be obese than women;8 • Thirty-five percent of adults of Hispanic ethnicity were overweight, compared to 33% of African Americans and 28% of Whites;9 and, • Adults between ages 55 and 64 years old were more likely to be obese of any other adult age group.10 These trends are similar to what is seen nationally as well as in our five-state region (Minnesota, Wisconsin, Iowa, North Dakota and South Dakota).

Men tend to have just slightly higher prevalence of obesity than women both regionally and nationally, with the regional exception of North Dakota, where men are nearly 6 percentage points higher than women.11 The percentage of Hispanic adults who are obese or overweight nationally is nearly 10 points higher than White adults.

That trend holds regionally as well, with the exception of South Dakota, where 29% of White adults were overweight compared to 27% of Hispanic adults.12 Health inequities in access to care, quality of care, and ability to make healthy lifestyle choices contribute to the imbalance between Hispanic and White adults.

Similarly, Minnesotans who do not have a college degree and who live in lowerincome households are more likely to be

The Journal of the Twin Cities Medical Society

overweight. Lack of education and poverty also contribute to health inequities.

More than 31% of adults in Minnesota who had less than a high school diploma were overweight in 2014, compared to only 22% of Minnesotans who had a college degree or higher.13 Adults with an annual household income below $50,000 were more likely to be overweight; those in households with less than $15,000 in annual income were the most likely.14 Low-income households often lack consistent access to adequate and nutritious food, and are contending with the stresses of poverty which are tied to obesity. Low-income neighborhoods frequently lack full-service grocery stores and farmers markets; low-income households are less likely to have their own vehicle to use for regular food shopping; and, when available, healthy food may be more expensive.15 Disparities in health are also documented in rural areas, including Greater Minnesota. People living in rural areas have less access to health care services due to lack of both doctors and transportation; are less likely to have health care insurance; are more likely to live in poverty; and suffer from chronic illnesses.16 Although the difference is not dramatic, adults in the Twin Cities tend to be slightly less obese than in Greater Minnesota. In 2012, 25% of Twin Cities adults were obese compared to 28% in Greater Minnesota.17 The gap is more pronounced nationally; the National Rural Health Association noted in 2012 that nearly 40% of rural adults were obese compared to 33% of urban adults.18 (Continued on page 18)

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17

State of Obesity Obesity in Minnesota (Continued from page 17)

Obesity in Children

Obese children are less likely to reach a healthy adult weight. They are at increased risk for chronic conditions such as type 2 diabetes, high blood pressure, high cholesterol, asthma, sleep apnea and depression.

However, modest lifestyle changes that will result in a healthier weight are more achievable before adulthood — which is one reason childhood obesity has become a significant focus of public health and health care programs in recent years.

With education and support, overweight children can make changes that will have significant lifetime benefits.

In 2015, MN Community Measurement (MNCM) and MDH released the results of a newly-developed measure on the rate of pediatric overweight counseling in Minnesota. The measure is included in Minnesota’s Statewide Quality Reporting and Measurement System. The measure evaluates how many patients ages three to 17 who had a Body Mass Index percentile of 85 or above, which is considered

overweight or obese, received counseling on physical activity or nutrition at their well child preventive care exams.

The first-year results indicated that 28.6% of Minnesota children and teens were overweight or obese in 2014; of those, 85% received at least one of the following interventions for both physical activity and nutrition: • Discussion of current behaviors (e.g., eating habits, participation in sports, exercise routine); • Provide counseling, guidance and/or educational materials; and • Refer patient for additional education or counseling (e.g., healthy lifestyle classes, nutritional therapy).

Well child exams were chosen as the point of focus because they are the primary, and sometimes only, point of contact between young patients and health care providers where preventive care and healthy behaviors are a focus.

We know far less about how childhood obesity differs by patient population than adult obesity. National studies indicate that nearly 40% of African American

and Hispanic children are overweight.19 And the 2013 Minnesota Student Survey suggested that male students were twice as likely to be considered obese (calculated based on student-reported heights and weights) than female students.20 MNCM hopes to begin segmenting the results of the Pediatric Overweight Counseling measure by sociodemographic factors in the near future. Since this data is collected by MNCM directly from medical groups, it will provide the most precise indication of where disparities exist in childhood obesity in Minnesota.

Erin Ghere, MPP, leads MN Community Measurement’s communications, marketing and community engagement efforts, which includes all MNCM publications, websites, media relations, consumer engagement and membership efforts. She earned her Master’s in Public Policy from the University of Minnesota, with a focus on women’s health and public health.

References available upon request.

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March/April 2016

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Sponsored Content

Integrated Health Care Approach Research-Driven Strategies Improve Outcomes for Weight-Loss Surgery Contributed by Daniel B. Leslie, M.D., Director of Bariatric Surgery, University of Minnesota Health

Innumerable studies have shown that successful weight loss is associated with better control of diabetes and other diseases associated with obesity. The National Institutes of Health recommends that patients with obesity target a weight loss of 10%. According to recent studies, a 10% weight loss may be achieved by as many as 36% of patients after one year of intensive lifestyle intervention.1 With surgical interventions, up to 99% of patients achieved a 10% weight loss after two years and 96% did after six years.2 Mortality rates for weightloss surgery are currently 0.2% or lower, although many primary care providers are reluctant to refer patients for weight-loss surgery due to fear of complications.

Weight-Loss Surgery

Because our M Health physicians have a long history of researching and providing bariatric surgery, we recognize the health benefits and some of the more serious long-term side effects of weight-loss operations involving the small intestine.

Our program has treated more than 2,000 patients with weight-loss operations over the past eight years. Success in weightloss surgery outcomes for our patients is dependent on several factors: • Engaging patients about their longterm health goals • Selecting an operation that can help promote healthy eating and weight loss and avoiding those that will interfere with their long-term health goals • Optimizing preparation of patients for surgery 20

March/April 2016

Incorporating research-driven strategies to document the mechanism and efficacy of these metabolic interventions Patients are potential candidates to undergo weight-loss surgery if they have a body mass index (BMI) of 40 kg/m2 or greater or a BMI between 35 and 39.9 kg/m2 and one or more serious comorbid conditions, such as diabetes, obstructive sleep apnea, or hypertension.

Four operations to treat these levels of obesity are recognized: vertical sleeve gastrectomy, Roux-en-Y gastric bypass, adjustable gastric banding, and biliopancreatic diversion with duodenal switch. All are performed laparoscopically at University of Minnesota Health facilities; however, we have identified that some are becoming more prevalent.

•

Procedure Selection

From an analysis of a large collection of national data, our bariatric-team researchers have documented a drop in Roux-en-Y gastric bypass surgeries, from 52% of all bariatric procedures in 2008 to 32% in 2014, as well as a decrease in adjustable gastric banding procedures, from 42% of procedures in 2008 to only 4% in 2014.

Vertical sleeve gastrectomy procedures, however, rose from 3% of procedures in 2009 to 52% in 2014.3 It is fully expected that this trend will continue.

These patterns in procedure selection are also reflected in the University of Minnesota bariatric surgery program. In 2015, the Roux-en-Y gastric bypass accounted

for only 2.9% of procedures, while our patients chose vertical sleeve gastrectomy 95% of the time.

A better understanding of the shortand long-term risks involved may have led to this large shift in procedure choice over the past eight years. FDA studies documenting weight-loss outcomes after implantation of gastric bands (LapBand and RealizeBand) showed that patients lost on average about 40 pounds after surgery.

Patient frustration with the gap between expected and achieved weight loss led, in many cases, to procedures where the implanted bands were over-tightened.

This approach resulted in side effects or complications and, often, subsequent band removals. Some complications required emergency room visits, hospitalizations, or surgery to resolve. As a result, the demand for adjustable gastric band procedures dropped as patients came to understand that most bariatric surgeons were taking out more bands than they were placing.

The vertical sleeve gastrectomy became a stand-alone bariatric procedure in 2010. The procedure involves removal of a large volume of the stomach without altering the small intestinal anatomy. A narrow tube is made from the remaining stomach, which assists patients in foodvolume and hunger control. Because there is no intestinal rearrangement, patients do not suffer the effects of micronutrient malabsorption, which is commonly diagnosed after the Roux-en-Y gastric bypass operation. With vertical sleeve gastrectomy, food follows a normal pathway through the

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stomach, and protein deficiency does not develop as a result of malabsorption. Peptic ulcer disease is not frequently seen, though if present, all portions of the stomach and duodenal anatomy can be visualized after surgery. The main risks associated with vertical sleeve gastrectomy include staple line leak (2%), stricture (1%), and bleed (1%).

These events occur almost exclusively in the perioperative timeframe. Heartburn and reflux may occur as well, necessitating long-term acid reduction. The long-term outcomes after sleeve gastrectomy are not established. At three years, weight loss after sleeve gastrectomy is over 20%.4

dependent on preoperative preparation. It also helps align their interests with those of their primary care provider and surgeon.

In a study of a large group of patients undergoing Roux-en-Y gastric bypass between 2009 and 2012, our bariatric surgery outcomes team noted significant benefits in preoperative weight loss. Patients who lost 10 pounds or more (24 pounds average) before surgery had a total weight loss of 90 pounds two years after surgery. Those who lost fewer than 10 pounds (4 pounds average) had two years after surgery, a total weight loss of 55 pounds.

Patient Preparation

Long-Term Postsurgical Care and Weight Management

In the University of Minnesota Health bariatric surgery program, overall health considerations are the number one objective. At the start, an evaluation of the patient’s nourishing food choices and eating behaviors, mental health and psychosocial support, physical activity levels, damaging substance use and behaviors, and sleep patterns is conducted. Appropriate interventions are recommended as part of preoperative planning.

We make smoking cessation mandatory among our patients. We check patients’ progress through examining biochemical markers (typically gathered through urine cotinine testing). Patients with a history of tobacco addiction, moreover, are no longer offered procedures that might interfere with their long-term health. Tobacco use in association with the Roux-en-Y gastric bypass operation has a fairly high incidence of peptic ulcer disease and its manifestations, including upper gastrointestinal bleeding, stricture, or perforation.

Our weight-loss surgery program requires patients to pursue weight loss prior to surgery. Significant medical data suggest that even a little weight loss can improve health conditions such as diabetes, heart problems, and obstructive sleep apnea.

Weight loss can reduce the risks associated with laparoscopic surgery, which puts some stress on the body, and allow for better outcomes. It can also provide the surgeon with a better view of the upper stomach so that the operation can be performed more efficiently. By working to reduce their weight, patients better understand that surgery is not a quick fix and that long-term outcomes are highly MetroDoctors

Postsurgical follow-up is more frequent during the first year after surgery and then routine laboratory testing and visits occur at annual intervals. Patients manage a healthy weight with the assistance of an interdisciplinary team of medical weight-management providers, registered dieticians, physical therapy experts, and psychologists.

FDA-approved medications to control appetite and cravings may be prescribed to assist with food intake behaviors, aid in treating weight regain, or provide a modicum of control once plateau weights are achieved. Patients are also assisted with understanding what their healthy weight targets may be and how they differ from unrealistic ‘ideal’ weight targets, which may not be achievable in a healthy way.

Our colleagues in interventional and luminal gastroenterology help manage side effects and complications. They assist with endoscopic ultrasound-guided and complex pancreatobiliary interventions, along with endoscopic treatments of gastro-esophageal dysfunction. Hematology and endocrinology evaluations help in managing iron and vitamin deficiency as well as side effects related to post-gastric bypass hypoglycemia.

Research on Weight-Loss Procedures

Since the 1960s, University of Minnesota faculty have made rich contributions to the field of metabolic research, achieving new discoveries and seeking to make weight-loss operations even more effective.

In the past 10 years our research team has

The Journal of the Twin Cities Medical Society

completed national studies on intragastric balloon implantation (RESHAPE DUO, FDA-approved, 2015), vagal blocking (Enteromedics Maestro Device, FDAapproved, 2015), and adjustable gastric band implantation (REALIZEBAND, FDA-approved, 2007), as well as studies on two endoscopic weight-loss procedures (TOGA and ESSENTIAL studies).

We are currently conducting an international randomized study evaluating methods of diabetes control after gastric bypass, comparing intensive medical treatment to medical management alone. This study has documented improved glycemia, systolic blood pressures, and cholesterol control after Roux-en-Y gastric bypass.

The durability of this effect is being further evaluated.

A separate focus is the study of adipose tissue biology and the complex mechanisms associated with rapid weight loss after surgery. We are also seeking to better understand changes in the gut microbiome. Obesity is associated with a significant alteration in the gut microbiome, which changes dramatically after surgery.

In controlled settings, patients have been providing stool samples so that these changes can be documented and better understood. Characterizing these changes will be critical towards understanding how we might better improve outcomes in the future.

For further information on our program, please visit umnwls.org.

References available upon request.

March/April 2016

21

State of Obesity

Treating Obesity Getting to Know the Weight Loss Medications

O

besity is a leading preventable cause of death in the United States. Obesity and overweight contribute to type 2 diabetes, heart disease, stroke, hypertension, dyslipidemia, obstructive sleep apnea, nonalcoholic fatty liver disease, osteoarthritis, and some types of cancer (uterine, breast, colorectal, kidney).

Additionally, the psychosocial implications of obesity such as depression and social discrimination have a significant negative impact on quality of life. Furthermore, the economic costs of obesity are extraordinary.

Data from the National Health and Nutrition Examination Survey, 2009-2010 show that 68.8% of the U.S adult population is overweight and 35.7% are obese putting them at risk for the myriad of comorbidities previously mentioned. Studies have shown that even modest weight reductions of 5-10% of total body weight can significantly reduce disease risks. Therefore, it has become necessary for today’s health care providers to treat patients’ overweight and obesity in pursuit of improving patient health and quality of life.

Given the complexity of overweight and obesity, it can take a coordinated effort from a team of caregivers to manage overweight and obesity. Patients may be referred to a bariatrician who has special training in the treatment of overweight and obesity. Dietitians provide the necessary nutritional education. Physical therapists or personal trainers may devise an appropriate physical activity regime. Psychologists may be employed to address psychosocial contributors.

Bariatric surgeons provide surgical bariatric therapy for patients whose BMI is > 40 or

By Laurie Kaiser Sund, M.D., FAAFP

22

March/April 2016

> 35 with obesity related comorbidities.

Weight loss medications also play a role in the treatment of overweight and obesity.

Adding weight loss medications to a healthier diet and physical activity has proven more effective than diet and exercise alone in achieving significant weight loss and in maintaining a healthier weight. Fortunately, we have more tools in our toolbox than ever before. Weight loss medications approved prior to 1999 were approved by the FDA for short-term (a few weeks) use due to the concerns about transient efficacy and the potential for physical dependency. They are structurally similar to amphetamines.

Some have established themselves to be nonaddicting, but the FDA indication has not changed. Weight loss medications approved after 1999 are approved for chronic weight management.

Recent history has led to hesitation of many providers to prescribe weight loss medications. Phen-Fen, the combination of Phentermine and Fenfluramine was removed from the market in 1997 due to findings of valvular heart disease and pulmonary hypertension in susceptible individuals. Fenfluramine (the “FEN” in Phen-Fen) stimulates serotonin release and inhibits serotonin reuptake. Interestingly, the histopathological features of valvular disease with Phen-fen use was identical to that found in patients with carcinoid or ergotamine-induced valve disease. Fenfluramine and its metabolite norfenfluramine were examined and found to stimulate valvular 5-HT (2B) receptors which may have led to the valvular fibroplasia. Phentermine (the “PHEN” in phen-fen) acts by releasing norepinephrine in neurons.

There were no cases of valve disease in patients taking phentermine alone.

Weight loss medications are effective

in helping patients make the lifestyle modifications necessary to achieve a healthier weight. We now have a variety of medications to consider. Examining a patient’s problem list is fundamental in determining the appropriate agent and, just like managing other chronic diseases, scheduled follow-up visits are important.

Consider adjusting, changing, or discontinuing weight loss medication after 12 weeks if the patient has not achieved a 3-5% weight loss. Cost is also a consideration. Insurance coverage varies considerably but is improving. Becoming familiar with and then using the available tools in the toolbox are the first steps in helping impact health and quality of life through weight loss — one patient at a time.

See pages 23 and 24 for a list of currently available prescription weight loss medications.

Laurie Kaiser Sund, M.D., FAAFP is the Bariatric Medicine Medical Director for HealthEast. Dr. Sund graduated from the University of Minnesota Medical School and St. John’s Family Practice Residency Program in Maplewood. She is board certified in Bariatric Medicine. She has special interests in obesity related comorbidities; especially diabetes, PCOS and metabolic syndrome, preventive medicine, anti-obesity pharmacotherapy, nutrition, exercise, and wellness. Dr. Sund can be contacted at (651) 326-3600 or ldsund@healtheast.org for any questions related to bariatric medicine.

References available upon request.

MetroDoctors

The Journal of the Twin Cities Medical Society

MetroDoctors

The Journal of the Twin Cities Medical Society

March/April 2016

23

Generic: No

Orlistat 120mg, Alli 60mg (OTC)

Generic: Yes

Didrex 50mg tablets.

Generic: Yes

Bontril

Belviq Lorcaserin: (Class IV) Approved in 2012. Serotonin 2C receptor Generic: No agonist. Approved for chronic weight management. Approved for ages >18. Studies showed that 1/3 to almost 1/2 patients lost 5% of their total body weight. Blood pressure and cholesterol also showed improvement.

Orlistat: Approved in 1999. Gastrointestinal Lipase inhibitor. Inhibits dietary fat absorption by approximately 30%. Approved for weight loss, weight maintenance, and to reduce the risk of weight regain after prior weight loss. Approved for ages > 12. Contributes to improvement in lipids and blood sugars.

Benzphetamine: (Class III) Approved in 1960. Sympathomimetic.

Approved for short-term use.

Approved for ages > 12. Potential risk for tolerance, dependence and withdrawal symptoms.

Phendimetrazine: (Class III) Approved in 1960. Sympathomimetic.

Increases norepinephrine and dopamine. Approved for shortterm use. Approved for ages >17.

Tolerance develops within a few weeks. It is not clear whether phendimetrazine causes pulmonary hypertension.

Generic: Yes

Tenuate

10mg BID

1 capsule at each fat containing meal.

25- 50mg daily.

35mg tablet or capsule BID or TID or 105mg CR Capsules Daily.

$250/month

$165 for 270 capsules

$45 for 90 tablets

$85 for 90 105mg CR capsules $40 for 180 35mg tablets

$30 for 90 25mg tablets

25mg TID or 75mg CR daily.

*Warehouse Pharmacy Price

Diethylproprion: (Class IV) Approved in 1959. Sympathomimetic.

Increases Norepinephrine and dopamine. Approved for short-term use. Approved for ages > 16.

Dosage 15mg, 30mg, 37.5mg $20-$24 for 90 37.5mg tablets

Trade Name

Adipex P, Ionamin, Phentermine: (Class IV) Approved Suprenza in 1959. Sympathomimetic.

Increases Norepinephrine in the Generic: Yes CNS and suppresses appetite. Approved for short-term use though is commonly used chronically. Most frequently prescribed weight loss medication in the United States because of its effectiveness and affordability. Approved for ages > 16.

Drug

Currently Available Prescription Weight Loss Medications

Pregnancy, breastfeeding. Use with caution with SSRIs, SNRIs, MAOIs, triptans, bupropion, dextromethorphan, and St. John’s Wort due to the risk of Serotonin Syndrome.

Chronic malabsorption syndrome, pregnancy, breastfeeding. Use with caution in liver or renal impairment.

Similar to phentermine.

Similar to phentermine.

Pulmonary hypertension and otherwise similar to phentermine.

Uncontrolled hypertension, hyperthyroidism, glaucoma, coronary artery disease, history of drug use, pregnancy and nursing. Do not use with MAOIs or other stimulant medications.

Contraindications

May be useful in patients worried about or prone to side effects.

The 37.5mg tablet is easily cut in half. Always start with 1/2 tablet (18.75mg) daily or the 15mg capsule. If effects wane, take a 2 week break. If evening hunger is particularly problematic, 1/2 tablet in the am and 1/2 tablet at noon can be tried. Maximum daily dose is 60mg. Consider other strategies instead of prescribing higher than 37.5mg.

Pearl

Headache, dizziness, fatigue, nausea, dry mouth, constipation.

Oily spotting, flatus with discharge, fecal urgency, oily stool, oily evacuation, increased defecation, fecal incontinence. Postmarketing experience has shown rare acute liver injury.

Patients can receive a 15 day free trial by going to Belviq. com and a savings card to bring cost down to no more than $75/month. An online support program is provided to patients taking Lorcaserin at BelieveSupport.com.

Take separate from thyroid medication, seizure medication and cyclosporine. Must take a MVI daily to prevent deficiencies of the fat soluble vitamins. Watch for symptoms of hepatic injury.

Similar to phentermine. Wean slowly to avoid depressed mood.

Similar to phentermine. Phentermine is more affordable and equally effective.

Wean off to avoid depressed mood.

Similar to phentermine though possibly fewer initial side-effects.

Dry mouth, increased heart rate and blood pressure, insomnia, constipation, restlessness, increase in energy and focus.

Common Side Effects

24

March/April 2016

MetroDoctors

Vyvanse

Generic: No

Saxenda

Generic: No

Contrave

Generic: No

Qsymia

Trade Name

$1,000/month

$730 for 360 capsules (a 90 day supply) $45-70/month with CONTRAVE Complete Card

15/92 $675 for 90 capsules

*Warehouse Pharmacy Price

20,30,40,50,60,70mg $290 for 30 capsules capsules. Start at 30mg daily and increase if needed to a maximum daily dose of 70mg.

3.0mg titrated up in 0.6mg increments.

One Subcutaneous injection daily.

Titrate up to 8/90 2 capsules BID.

3.75/23, 7.5/46, 15/92

Dosage

Concomitant use with MAOI or other stimulant medications. Structural heart abnormalities, coronary artery disease, serious heart arrhythmia.

Personal or family history of Medullary Thyroid Cancer or Multiple Endocrine Neoplasia syndrome type 2, use of other GLP- 1 receptor agonists. Saxenda causes thyroid C-cell tumors in rats and mice.

Chronic opioid medication use, abrupt discontinuation of heavy alcohol use or benzodiazepines, Uncontrolled hypertension, seizures, anorexia, bulimia, MAOIs, pregnancy, breastfeeding.

Pregnancy, glaucoma, hyperthyroidism, MAOIs, carbonic anhydrase Inhibitors, other seizure medications, uncontrolled hypertension, coronary artery disease.

Contraindications:

Dry mouth, insomnia, decreased appetite, constipation, increase in heart rate, feeling jittery, anxiety.

Nausea, hypoglycemia, diarrhea, constipation, vomiting, headache, dyspepsia, fatigue, dizziness, abdominal pain and increased lipase.

Nausea, constipation, headache, dizziness, insomnia, dry mouth, diarrhea, vomiting.

Paraesthesias/dysgeusia, mood and sleep problems, constipation and dry mouth.

Common Side Effects

*COSTCO pharmacy prices as of January 2016. NOTE: Club membership is not required to fill a prescription at warehouse pharmacies.

Lisdexamfetamine: (Class II) Approved for Binge Eating Disorder (not for weight loss) in 2015. An ADHD stimulant medication with potential for abuse and dependence.

Liraglutide 3.0mg: Approved in 2015 for chronic weight management in adult patients. GLP-I Agonist. Potential risk of Medullary Thyroid Carcinoma and acute pancreatitis.

Naltrexone (an opioid antagonist) and Wellbutrin: (class IV) Approved in 2014 for chronic weight management.

Phentermine and Topiramate: (Class IV) Approved in 2012 for chronic weight management.

Phentermine was previously discussed. Topiramate is an extended release epileptic medication also used in migraine prevention. The mechanism of action related to weight loss is unknown. Approved for ages > 18.

Drug

Evaluate patients with cardiac complaints or unexplained syncope while taking Vyvanse. Prescription savings for patients of up to $720 over 12 months at vyvanse. com.

With the Saxenda Savings Card (Saxenda.com), patients will pay $30/month or save $200/month. In diabetic patients on other agents, make sure to check sugars frequently and adjust other medications down to avoid hypoglycemia. Discontinue promptly if pancreatitis is suspected.

Patients can go to www.readytolose.com for medication discounts and enrollment in the Scale Down program for personalized weight management support.

Wean off slowly to avoid seizure. Topiramate is teratogenic. Counsel female patients of reproductive potential to avoid pregnancy. Vivis ofers a “Free to Start” offer-a 14 day trial, monthly savings and a “Q and Me” support program. Phentermine and topiramate can be prescribed separately, both have generic options. Topamax is sometimes prescribed by psychiatrists to “offset” weight gain from antipsychotic medications. Topiramate inhibits carbonic anhydrase activity and may promote kidney stone formation.

Pearl

State of Obesity

The Journal of the Twin Cities Medical Society

Obesity and its Related Chronic Diseases from a Corporate Perspective Introduction Progress in prevention and treatment of infectious diseases has been partially offset by increased incidence in noncommunicable diseases such as diabetes, heart disease, and lifestyle-related cancers. The marked increase in prevalence of obesity over the past five decades has been recognized as a major source of this problem. Obesity and its sequelae incur an enormous personal, social, and economic cost.1 From a population perspective, obesity contributes to increased illness burden, reduced functional status and productivity, and higher costs of medical care. When applied to the corporate setting, obesity impacts almost all elements of business operations and performance, compromising corporate competitiveness.2 Obesity by the Numbers Globally, excess weight affects more than 2.1 billion people. Almost 30% of the global population meets overweight (body mass index (BMI) ≥ 25-29.9 kg/m2) or obesity (BMI ≥ 30 kg/m2) criteria based on body mass index, a staggering statistic when considering that it is nearly 2.5 times the number of people in the world who are undernourished. Current projected global prevalence of overweight and obesity is estimated at 50% by 2030.3 Furthermore, obesity is one of the top three global social burdens generated by human beings.

The global economic impact of obesity is roughly $2.0 trillion, or 2.8% of global Gross Domestic Product. Obesity, viewed through this lens, has the same impact on the global economy as armed conflict (armed violence, war, and terrorism) and only somewhat less than smoking (2.9% of global GDP).4 As BMI increases, so do

By Nicolaas P. Pronk, Ph.D. MetroDoctors

health care expenditures. The World Health Organization estimates that overweight and obesity is associated with 2% to 7% of global health care spending.

In the U.S., obesity rates have increased from approximately 13% in the late 1950s to 36% by 2010. Childhood obesity prevalence has tripled during the course of a single generation and adult obesity prevalence has increased to more than one-third of the U.S. population.5 Obesity-related medical expenditures in the U.S. were estimated at $147 billion in 2008 and were projected to reach $344 billion by 2018, effectively imposing a “tax” of $1,425 on every American.6 A Corporate Point-of-View From a corporate perspective, obesity is fast becoming a problem that can no longer be ignored. Over a span of three decades, between 1986 and 2011, obesity prevalence of the U.S. workforce doubled from approximately 15% to 30%.7 Obesity affects almost every aspect of running a company.

It affects a company’s human capital — its workers — due to its detrimental association with increased illness burden, reduced function, and increased disability. For example, obese employees file twice as many workers compensation claims, have 20% more doctor visits, and 26% more emergency room visits compared to their healthier weight counterparts. In addition, obese workers often face stigma, discrimination, and prejudice at many stages of the employment process, including hiring, wage determination, and job promotions.2,7 All these factors associated with obesity may be considered “costs” that affect the worker and in turn, the company.

Obesity negatively affects a company’s financial capital as associations with health care costs and productivity loss erode the finances available for a company to operate.

The Journal of the Twin Cities Medical Society

For example, obese workers incur on average $644 more in medical care costs, are 80% more likely to have work absences, and were 3.7 more days (7.7 vs. 4.0 days) absent from work than normal-weight workers.4 A corporation’s social capital is also affected by obesity due to impacts on worker performance. Perhaps not surprising given the fact that stigma and discrimination are particularly pronounced in the workplace setting, “getting along with co-workers” was noted to be negatively associated with obesity in a large multi-employer study.8 In today’s contemporary workplace, sedentary jobs are much more prevalent than five decades ago. Over the past 50 years, the need for physical exertion required to meet the demands of the job has reduced by approximately 100 calories per day. This seemingly minor shift in daily occupationrelated energy expenditure is purported to account for as much as 80% of the concomitant increase in body weight among the U.S. workforce.9 An additional consideration employers need to consider is the aging of the workforce and the associated changes in generations working alongside each other. By 2020, the workforce is projected to include 1% Traditionalists, 22% Boomers, 20% Gen X-ers, 50% Gen Y-ers, and 7% Gen Z-ers.

Five generations working alongside each other with varied worldviews and employment related perspectives — from the loyal traditionalists to the hyperconnected Gen (Continued on page 26)

March/April 2016

25

State of Obesity

Z-ers. Yet, obesity will be highly prevalent among all groups. Based on 2020 forecast data from the Future of the Workplace Survey data, obesity rates are projected to vary between 26.3% and 33.3% for the four older generations and be at 14.7% for the Gen Z generation. As such, obesity is likely to be a long-term corporate concern as much as it will remain a public health challenge.

The Challenge of Complexity Obesity is a defiant health problem, largely resistant to interventions designed to prevent it. Efforts designed to reduce obesity have struggled to provide clear-cut answers for the workplace setting. In general, populationbased interventions have generated small effect sizes and no single solution has created sufficient effect size to reverse the obesity trend among workers.10,11 Furthermore, as depicted in Figure 1, few interventions are successful at long-term maintenance of weight loss. Clearly, obesity is complex in its biological, social, psychological, and societal determinants and ramifications. The causes of obesity are complex, manifold, and interdependent. They are influenced by social, economic, financial, biological, and epigenetic triggers. Programs to address obesity at the workplace need to recognize this setting as a complex social environment.

Solutions need to be sought across all sectors of society — a seemingly reasonable approach considering all sectors will share benefits.

Multi-Sectoral Approaches to Obesity It is highly unlikely that a single solution will present itself to the challenge of obesity. It is also clear that no single entity “owns” the obesity problem. Rather, we should look for partnerships across multiple sectors in which companies and their leaders may play a certain role and provide a certain set of resources, but that are supported by other entities that extend the reach of activities way beyond the workplace walls. Whereas no single solution is likely to “fix” the problem, every single intervention is likely to have some degree of effect — cumulatively impacting upon the aggregate level. When such approaches are implemented in a multi-sectoral model and sustained over an extended period of time, successful outcomes may be 26

March/April 2016

Weight Loss (kg)

The Issue of Obesity and its Related Chronic Diseases (Continued from page 25)

Exercise Alone Diet & Exercise Diet Alone Meal Replacements VLCD Orilistat Sibutramine Advice Alone

6-mo

12-mo

24-mo

36-mo

48-mo

Figure 1. Average weight loss of subjects completing a 1-year weight management intervention based on a review of 80 studies (N = 26,455; 18,199 completers). (Reprinted from: Franz MJ, VanWormer J, Crain L, et al. Weight loss outcomes: A systematic review and meta-analysis of weight loss clinical trials with a minimum of 1-year follow-up. Journal of the American Dietetic Association. 2007;107(10):1755-1767. Copyright 2006 HealthPartners. Used with permission.)

generated.4 This means that employers need to provide resources and access to programs for their workforce. However, those resources should be coordinated with the families of workers, the clinics and physicians where employees and their families receive their care, local schools, and other partner organizations in the broader community.

From Workplace to Community Individual behavior, notably eating and physical activity behavior, is linked to excess body weight, but the environment in which workers find themselves is a powerful modifier to such behavior. The culture of the workplace, the normative influence of the organization on the workers, may be considered a causal factor in the complex system that surrounds the individual. Therefore, employers should consider efforts at multiple levels of the organization and with partners that can deepen and extend the results beyond the time that people are at work. The first and foremost of such partners should be the individual workers themselves.

Employers should consider acting at the individual level to provide access to programs that modify lifestyle behavior. They should leverage the tools available to them to help facilitate changes in the corporate environment and organizational culture to make these more conducive to healthy lifestyles and healthy weight. Such tools would include benefits design, corporate communications, the use of social media, creative ways to leverage technologies, and, of course, people.

In particular, corporate leaders need to be explicit in setting a vision for the company and be visible in supporting their managers and directors in carrying out such vision.

Going beyond the workplace, employers should intentionally include the family in programs designed to support healthy weight. Furthermore, when it comes to addressing obesity as a disease, a connection to primary care or other clinical programs would be ideal. This is an area of much interest and new models, informed by the rapidly changing clinical environment due to implementation of the Affordable Care Act, are emerging. For example, building upon the Chronic Care Model, a new integrated framework for the prevention and treatment of obesity has been introduced by the Obesity Solutions Roundtable at the National Academy of Medicine. This framework explicitly recognizes the connections between obesity and the various community stakeholders, including the employer.

Nico Pronk, Ph.D., is Vice President for Health Management and Chief Science Officer for HealthPartners and a Sr. Research Investigator at the HealthPartners Institute. He is also an adjunct Professor of Social and Behavioral Sciences at the Harvard T.H. Chan School of Public Health. His work is focused on connecting evidence of effectiveness with the practical application of programs, services, systems, and policies that measurably improve population health. He can be reached at Nico.P.Pronk@ HealthPartners.com References available upon request.

MetroDoctors

The Journal of the Twin Cities Medical Society

Preventing Type 2 Diabetes

By Identifying and Addressing Prediabetes

M

ost of us are aware of the diabetes epidemic in this country. The current number of people with diabetes in the United States is 22 million, a four-fold increase since 1980. The projected number of 53.1 million people diagnosed with type 2 diabetes by 2025, with an associated annual medical and societal cost of 500 billion dollars, should be extremely concerning to our society. As medical providers, we have a critical role to play in curtailing this epidemic. Identifying and addressing prediabetes with our patients is a crucial way to make a difference in this fight.

Even more astonishing than the projected number of people with type 2 diabetes is the current number of people with prediabetes. Current estimates are that 86 million people in the United States have prediabetes, and 90% of them are unaware of the diagnosis. Of this 86 million people, 15-30% will develop diabetes within the next five years if changes don’t occur.

Identifying prediabetes in our patients is an important first step for us as providers. Recognizing that diabetes is preventable should motivate us to diagnose and address this issue with our patients. Patients at increased risk for prediabetes should be screened for the disease. Factors putting a person at high risk include age 45 years or older, being overweight, exercising less than three times a week, a family history of diabetes, high risk race/ethnicity (Latino, African American, Asian, American Indian, Pacific Islander), a diagnosis of polycystic ovarian syndrome, or having been diagnosed with gestational diabetes during pregnancy.

Diagnosing prediabetes is a clinical diagnosis made by one of three lab values:

1.

Glycosylated hemoglobin (HgbA1C) between 5.7% and 6.4%.

2. Fasting blood glucose between 100 and 125.

3. A blood glucose between 140 and 199 two hours after a 75 gram oral glucose load (a glucose tolerance test).

Increasing screening rates will increase rates of diagnosis. Multiple members of the health care team can play a role in increasing the screening rates. Having posters hanging in the lobby or exam rooms of your clinic that talk about risk factors for prediabetes and diabetes can trigger patients to ask you or your staff about screening.

Once the diagnosis of prediabetes has been made, communicating with your

By Kathryn Justesen, M.D. MetroDoctors

The Journal of the Twin Cities Medical Society

patient is key. Using verbiage that emphasizes they can avoid diabetes is imperative. There is hope if patients are found to be prediabetic! Making successful lifestyle changes can reduce a person’s risk of progressing from prediabetes to diabetes by 58%. Modest weight loss of 5-7% of body weight through a combined program of reducing calorie intake and increasing physical activity constitutes successful change.

(Continued on page 28)

American Diabetes Association Alert Day is March 22, 2016.

Consider using this day as a clinic-wide in-house prediabetes screening event! You could incorporate any of the following: • Give informational pamphlets at check-in/registration front desks for patients to take and read.

• Encourage your lab staff to discuss and offer prediabetes screening to all people at risk whom are getting their blood drawn.

• Encourage your rooming staff to discuss prediabetes with all patients, especially those falling into the high risk categories.

• Enable medical staff to order screenings and provide information on prediabetes.

• Hang posters on the wall in the lab waiting area to facilitate this discussion.

Such posters can be found and downloaded at no cost at www.cdc.gov/ diabetes/prevention. On that same valuable website is a prediabetes risk quiz which you can encourage your patients to take to assess their individual risk.

Another valuable website, which also has a type 2 diabetes risk test, is www. diabetes.org.

• Have a table in the waiting area where patients can inquire about prediabetes as another way to educate your patients on the risk factors as well as ways to prevent diabetes.

• Consider instituting a reward program for recognizing staff that are successful in increasing your screening rates.

• Involve Community Health Workers or Patient Advocates in education and awareness building with patients during their visits.

March/April 2016

27

State of Obesity Preventing Type 2 Diabetes (Continued from page 27)

Many patients will not realize that lifestyle changes can allow them to avoid the diagnosis of diabetes. They may feel that due to a strong family history, it is inevitable that they will be diagnosed with diabetes.

Or, they may think that a significant weight loss is necessary, without knowing that losing only 5-7% of body weight (10-14 pounds for a 200-pound person) can dramatically decrease their risk of diabetes. Empowering your patients to make this change will help them immensely. Patients look to their health care home for advice, motivation, and incentive to change — we must be that resource for them!

Of course, we must provide accessible resources to help our patients make the lifestyle changes. The Center for Disease Control leads a National Diabetes Prevention Program (NDPP) which emphasizes an evidence-based lifestyle change program to help people institute the changes that can lead to diabetes prevention. This program is a national effort to (1) Raise awareness of prediabetes, (2) Share information about the National Diabetes Prevention Program,

(3) Encourage participation in local lifestyle change programs, and (4) Promote the National Diabetes Prevention Program as a covered health benefit. Across the state of Minnesota there are facilities which offer NDPP classes for the community. These classes are led by a trained lifestyle coach in a classroom setting. The coach facilitates a small group of participants in learning about healthier eating, physical activity and other behavior changes over the course of a year (16 one-hour weekly sessions, followed by monthly maintenance sessions for added support to help them maintain their progress).

Read about this success story from a participant in the NDPP classes: Jill P is an African-American female who was overweight most of her adult life with a family history of diabetes. She has a plate full of personal commitments that made it easy for her to put her health low on her priority list.

Jill became a participant at her local National Diabetes Prevention Program offered through her church by the Stairstep Foundation. The program helped her focus on placing her health as a top priority and to make the little changes that could impact her overall health. She

Your Link to Mental Health Resources

learned from a trained lifestyle coach about what foods to eat, what portion control means, how to exercise, how to manage daily stress, and more. With help and support from the program she was willing and motivated to make changes in her lifestyle. Her husband became inspired as well. Together they implemented small changes into their family diet and exercised together.

At the end of the program she exceeded 7% weight loss and her husband’s HgbA1C sank from 6.2% to 5.5%, and overall the couple lost more than 20 pounds each.

An updated list of current NDPP classes can be found at http://www.minneapolismn. gov/health/living/diabetes. While the classes are not generally covered by insurance, the NDPP does pursue grant funding to cover the cost of the classes for people unable to pay out of pocket. In Minneapolis, the Minneapolis Health Department offers free NDPP classes through four organizations.

Several YMCA sites offer NDPP classes.

Clinics also can establish an in-house diabetes prevention program. To learn more about community-based programs or assistance in starting your own in Minneapolis, please contact Martina Campbell at martina.campbell@minneapolismn.gov. Details on other CDC and NDPP resources available in the community and for providers can be found at www.icanpreventdiabetes.org. This site includes a tool kit for providers with a link to a webinar on how to screen, counsel, refer and follow up for diabetes and prediabetes.

Also provided on that site is an algorithm for prediabetes screening and treatment, and fact sheets for both providers and patients.

Type 2 diabetes is a preventable disease.

Identifying and addressing the issue for the 89 million Americans with prediabetes and providing them with the resources for making successful lifestyle changes will help curb the epidemic facing our country. Use March 22, 2016, the American Diabetes Association Alert Day, as motivation for stepping up your screening and diagnosis of prediabetes and diabetes.

Kathryn Justesen, M.D. is an assistant professor in the University of Minnesota Department of Family Medicine and Community Health and faculty at the North Memorial Family Medicine Residency program. In addition, she is serving as the TCMS representative on the City of Minneapolis Diabetes Prevention Network.

Resources available upon request.

28

March/April 2016

MetroDoctors

The Journal of the Twin Cities Medical Society

is for Groundbreaking.

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And now, we’re breaking new ground by bringing patients an all-new, state-of-theart Clinics and Surgery Center designed around their needs. With unmatched access to the latest treatments and clinical trials, and patient-friendly location, hours and amenities—we are now open and excited to welcome your patients.

M Health is for all of us.

Visit mhealth.org

M Health Clinics and Surgery Center, 909 Fulton St. SE, Minneapolis, MN 55455 The University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center.

Clinics • Hospitals • Specialty Care

State of Obesity

Minnesotans for Healthy Kids Coalition— Taking Action for a Healthier Minnesota

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ver 60% of Minnesota adults are now overweight or obese1 and 27% of Minnesota children are overweight or obese.2 What has changed to create this tripling of overweight and obesity among children in Minnesota and the nation over the last three decades? Communities have been asleep at the wheel as subtle but destructive changes have been taking place.

Communities have been built to discourage walking and biking. Children’s health has been forgotten as the primary objective of our school food programs. Opportunities for physical activity have been quietly removed from schools, and physical-education programs have been scaled back — ironically these important activities have been sacrificed to focus on academic achievement despite evidence that physical activity enhances brain function.

How does Minnesota begin to reverse the tide of these negative health consequences that have been quietly building for more than a generation?

The Minnesotans for Healthy Kids Coalition (MHK) has undertaken the work of reversing this trend and improving the health of Minnesota’s children through public-policy measures at the Minnesota State Capitol.

The MHK Coalition has successfully passed legislation at the Minnesota Legislature over the last eight years — working against the tide to reverse the damaging impacts of childhood obesity and overweight. The coalition consists of health, education, academic, and child-focused organizations that have been unified by a mission to promote healthy eating and increase physical activity to improve health and reduce obesity among Minnesota’s children through public-policy change.

By Rachel Callanan

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The most recent Minnesota Student Survey, a triennial statewide survey last administered by the Minnesota Department of Education in 2013 to public school students in grades 5, 8, 9 and 11, gives an indication of what we are up against. Less than half of respon- Minnesotans for Healthy Kids Coalition Day at the Capitol, 2015. dents across all grades report engaging in the recommended 60 set of physical education benchmarks minutes of daily physical activity in five or for Minnesota schools. The MDE more days of the last week.3 The Minnesota study found that fewer than one in four Student Survey also found that 60 percent schools serving grades K-5 provided the of respondents report they have not eaten recommended 150 minutes per week of vegetables at least once a day in the last seven physical education time. days and one out of 10 report eating no • MHK has been a strong champion of vegetables at all in the previous week.4 the Statewide Health Improvement MHK has led the charge at the state Program (SHIP), which devotes $35 capitol and joined in partnership with many million per biennium to local public organizations to advance key legislative polihealth strategies to promote physical cies. MHK’s focus is to support evidenceactivity, healthy eating, and reduced based public policies that will truly have tobacco use.7 SHIP has built the coma statewide impact on increasing physical munity capacity of local public-health activity and healthy eating for Minnesota’s offices to tackle evidence-based stratechildren. gies that promise to improve health, MHK’s work has yielded real results in reduce health-care costs, and “make the changing the policy landscape in Minnesota: healthy choice the easy choice” through • MHK passed legislation to strengthen local policy, systems and environmental physical-education classes by requirchange. ing statewide minimum standards and • MHK supports a healthier school-food secured funding for the Minnesota environment at both the state and fedDepartment of Education (MDE) to eral level, including state funding for conduct a study of whether that legisFarm to School programs and increased lation has been implemented successreimbursement by the state for healthier fully. The study yielded mixed results school lunches. MHK fought to enact for school districts and prompted the and defend the Healthy Hunger-Free coalition’s work to introduce a stronger Kids Act at the Federal level, which

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updated and improved the nutrition standards for school food.

• And the list goes on…

MHK is now embarking on one of their most ambitious policy agendas yet for the 2016 legislative session: • MHK is playing a leadership role in elevating walking and biking in the broader statewide transportation discussion — MHK seeks to secure $50 million per year for active-transportation investments as part of a promised statewide multimodal-transportation package.

• This fall MHK launched a campaign to secure $10 million per year to ensure healthy food access in low-income communities across the state. MHK’s proposed Good Food Access Fund would provide loans and grants to expand the healthy-food-retail environment in underserved communities. A recent poll commissioned by the Center for Prevention at Blue Cross and Blue Shield of Minnesota found that for nearly half of Minnesotans — 49 percent — not having a store nearby that sells healthy food, directly impacts what they eat.

• Additionally, MHK continues to work on strengthening physical education in Minnesota schools, requiring stronger grade-specific curriculum outcomes, or benchmarks, to ensure every Minnesota child learns the skills for a lifetime of physical activity.

MHK’s strength is derived from the diversity and collaboration of its member organizations and needs your help, your voice, and your ideas to make healthy eating, active living, and reducing childhood obesity top priorities for policymakers and Minnesotans.

Please like MHK on Facebook at www.facebook.com/MinnesotansforHealthyKidsCoalition and visit their web site www.heart. org/MNHealthyKids to learn more about how you can join in efforts to change the landscape in Minnesota to ensure a healthier future for our kids.

Rachel Callanan is Regional Vice President of Advocacy for the American Heart Association and chair of the Minnesotans for Healthy Kids Coalition.

References available upon request.

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Edward P. Ehlinger, M.D., Receives Shotwell Award

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he 2015 Shotwell Award was presented to Edward P. Ehlinger, M.D., MSPH, at the January 5, 2016 annual meeting of the Abbott Northwestern Medical Staff. Chris J. Johnson, M.D., Chair of the Twin Cities Medical Society Foundation (TCMSF) presented the award.

Edward P. Ehlinger, M.D., MSPH, currently serves as Commissioner of the Minnesota Department of Health. He is responsible for directing the work of the Minnesota Department of Health to safeguard and improve the health of all Minnesotans. Dr. Ehlinger is board certified in both Pediatrics and Internal Medicine; he received his medical degree from the University of Wisconsin, Madison and his Master of Science degree in Public Health, majoring in Maternal and Child Health, at the University of North Carolina, Chapel Hill. He completed an internship in Internal Medicine at Hershey Medical Center, Pennsylvania State University; and a Pediatric residency followed

by an Internal Medicine residency at the University of Utah Medical Center, in Salt Lake City. In addition, Dr. Ehlinger served as a fellow in the Robert Wood Johnson Clinical Scholars Program, a Bush Clinical Fellowship, and a Salzburg Fellow.

Dr. Ehlinger has spent the majority of his 35-year career advocating for public health and medicine, defining public health as “what we as a society do collectively to improve health for all.”

Presenting the award, Dr. Johnson stated, “In recognition of his leadership as Minnesota’s Health Commissioner, a physician leader and a consummate advocate for public health, I am honored to present the 2015 Shotwell Award to Edward P. Ehlinger, M.D.” The Shotwell Award was established

by Metropolitan Medical Center in 1971 in recognition of the support and dedication of the Shotwell Family. Upon the closing of Metropolitan-Mount Sinai Medical Center in 1991, the West Metro Medical

The Shotwell Award was presented to Edward P. Ehlinger, M.D. (left) from TCMS Foundation Chair Chris Johnson, M.D.

Society/Foundation (now TCMSF) assumed responsibility for selecting the recipient of the Shotwell Award. Abbott Northwestern Hospital and Medical Staff has generously provided funding for the Shotwell Award since 2003. A plaque recognizing all the award recipients resides in the Sister Kenny Pavilion on the Abbott Northwestern campus.

MinnesotaHelp.info® is brought to you by the State of Minnesota to connect people with services in their communities.

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TCMS Holds 2016 Annual Meeting Carolyn McClain, M.D. Installed as President Executive Committee Appointed

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arolyn McClain, M.D. was installed as President of the Twin Cities Medical Society at its annual meeting held on Tuesday, January 12, 2016. McClain grew up in Sunfish Lake, Minnesota, graduated from John Hopkins University and completed an emergency medicine residency at Hennepin County Medical Center. In 2007 she joined Emergency Physicians Professional Association (EPPA) and currently serves as the Assistant Medical Director of Urgency Rooms and is the Quality Improvement Assistant Director at EPPA. The following physicians join Dr. McClain on the 2016 TCMS Executive Committee: • Matthew Hunt, M.D. FRCS – President-Elect • Kenneth Kephart, M.D. – Immediate Past-President • Nicholas Meyer, M.D. – Treasurer • Thomas Kottke, M.D., MSPH – Secretary • Andrea Hillerud, M.D. – At Large Member • Ryan Greiner, M.D. – At Large Member Sue Schettle, CEO provided the annual report of the Twin Cities Medical

Society and discussed the 2016 areas of strategic focus.

Representative Erin Murphy shared her thoughts on Minnesota’s state of health and described how her nursing experience plays a role in her career. Murphy was elected into the House in 2006 and is currently in her fifth term, serving as the

Guest speaker Representative Erin Murphy DFL (64A) addresses the TCMS Board of Directors and guests.

Deputy Minority Leader. She also serves on the Health and Human Services Finance Committee and Legacy Funding Finance Committee. She received her Bachelor of Science in nursing at the University of Wisconsin-Oshkosh and her MA degree in organizational leadership at the College of St. Catherine’s. Throughout her decade of service, Representative Murphy has been involved in almost every major

New board members (from left): Kendal Farrar, M.D., Jennifer Kuyava, M.D., Daniel Bernstein, Jennifer Janssen, Rishi Kumar, M.D., Nick Schneeman, M.D., and Caleb Schultz, M.D.

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Kenneth Kephart, M.D. accepts outgoing TCMS President’s Award from Carolyn McClain, M.D.

health care policy and finance change. She is currently collaborating with the MMA on prior authorization reform and working to close Minnesota’s exemption loophole for vaccinations. Murphy discussed how nursing gives her a deeper view into the policy work she is a part of and reviewed her goals for the upcoming Legislative Session.

Dave Thorson, M.D. President of the Minnesota Medical Association highlighted what’s to come in 2016 from the MMA, and their plans for the 2016 Legislative Session.

The First a Physician Award was Presented to Charles Crutchfield, III, M.D. with his family present. See related article on page 34.

Kenneth Kephart, M.D. was recognized with the 2015 President’s Award as he completes his term. He will continue to serve on the Board of Directors as the immediate past-president. He also serves as the Medical Director for Honoring Choices Minnesota.

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CAREER OPPORTUNITIES

See Additional Career Opportunities on page 35.

First a Physician Award The First a Physician Award was presented to Charles Crutchfield, III, M.D., at the January 12, 2016 Twin Cities Medical Society Board of Directors annual dinner.

While presenting the award, TCMS President Dr. Carolyn McClain read an excerpt

from the nomination letter the TCMS Executive committee received from fellow Dermatologist, Dr. Neil Shah, stating that the generous and ongoing support he received from Dr. Crutchfield throughout his career was not unique. Dr. Crutchfield has selflessly mentored and supported hundreds of physicians throughout his career.

Dr. Crutchfield accepted the award with his family present including his father Charles Crutchfield, Sr., M.D. The First a Physician Award is presented annually to a member of the Twin Cities Medical Society who selflessly gives his/her time and energy to improve the health of their patients, has made a positive impact on organized medicine and the medical community’s ability to practice quality medicine, and/or has been instrumental in improving the lives of others in our community.

BEYOND TREATING, THERE’S CARING W E L L A N D BE YO N D Fairview Health Services seeks physicians with an unwavering focus on delivering the best clinical care and a passion for providing outstanding patient experience.

Be part of a collaborative team that puts patients at the center and is transforming health care for today and tomorrow.

We currently have opportunities in the following areas: • • • • • •

Allergy Dermatology Emergency Medicine Family Medicine General Surgery Geriatric Services

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Hospitalist Internal Medicine Med/Peds Neurology OB/GYN Orthopedic Surgery

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Pain Medicine Pediatrics Psychiatry Sports Medicine Urology Vascular Surgery

To learn more, visit fairview.org/physicians, call 800-842-6469 or email recruit1@ fairview.org

TCMS President Dr. Carolyn McClain joins Dr. Crutchfield and his family.

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March/April 2016

fairview.org/physicians TTY 612- 672-7300 EEO/AA Employer Sorry,

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LUMINARY of Twin Cities Medicine

By Marvin S. Segal, M.D.

C. WALTON LILLEHEI, M.D.

The year was 1960 when the 3rd year medical student entered the darkened surgical observation chamber above the main cardiac surgery operating room. Down through the dome-like glass he saw the gray tiled wall of the room below occupied by a centrally placed table with an anesthesiologist at the head of the draped patient, a pump team running the life maintaining oxygenator, gray scrub suited circulating nurses scurrying about, and the gowned surgical team concentrating on the task at hand. The room was mostly silent save for an occasional muffled comment, though there was little doubt that the “Father of Open-Heart Surgery” was in charge.

Dr. Walt Lillehei was born in Minneapolis and earned five degrees at the U of M. Except for a period as Chief of Surgery at the Cornell University Medical College, he practiced, researched and taught at his alma mater from1951 until his death in 1999.

Dr. Lillehei, with Dr. John Lewis, performed the first surgical repair of an open heart in 1952 using hypothermia — which significantly reduced body temperature, slowed blood flow and thereby decreased vital organ oxygen requirements. Though successful, it had been previously determined through animal experiments, that time would be a limiting factor as the hypothermic state could only be maintained for a very short period . . . just minutes.

Therefore, for more complex cardiac procedures, a method would be necessary to stop blood flow to the (lungs and) heart which allowed it to be opened and repaired while blood continued to be oxygenated and pumped to the brain and rest of the body. So, using information gained from fruitful dog surgical research, the technique of cross-circulation was established.

In 1954, Dr. Lillehei repaired a septal defect while the patient’s blood vessels were connected to those of an adjacent living donor while a simple pump between them moved oxygen rich and “used” blood in the proper back-and-forth directions. This admittedly risky method was used in nearly 50 open-heart surgeries — correcting previously incurable defects, though not without mortalities which, in turn, stimulated yet a further creative search.

A bit later, Lillehei and Dr. Richard DeWall, developed and placed into use a successful prototype of the heart-lung oxygen bubbler pump which is still used today. Aha — a safer 36

March/April 2016

and more effective “key to open” an impaired heart was found!

Unfortunately, on occasion the more convenient access to surgery within the heart — with its inherent electrical grid — caused an interruption of necessary pathways which in-turn resulted in the unwanted creation of a heart block.

C. Walton, seemingly never at a loss for creative solutions, stimulated a U of M electrical contractor (Earl Bakken, later of Medtronic fame) to invent the first battery powered portable pacemaker. Dr. Lillehei implanted the first of those, and by 1960 reported in JAMA of 66 patients carrying them about in shoulder holsters.

Yes, the amazing career of Dr. Walt can be added to and further recounted . . . a WWII Bronze Star; a 1955 recipient of the very prestigious Lasker Award; among the earliest developers and implanters of prosthetic heart valves; author of hundreds of medical literature contributions; the training of countless cardiac surgeons including Drs. Christiaan Barnard (who performed the world’s first heart transplant) and Norman Shumway (who devised a groundbreaking technique in transplantation).

Our Luminary has been widely and variously described as brilliant, imaginative and a true medical genius. How fortunate it was for that medical student to have had the privilege of witnessing him at work so many years ago.

This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine.

Please forward names of physicians you would like considered for this recognition to Nancy Bauer, managing editor, nbauer@metrodoctors.com.

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