Obesity Medicine For Internists

[The kitchen sink]

I hope these individual are also on a proper diet and exercise regimen before the medications and gastric sleeves get done.
Proper diet as if saw a dietitian, did own research on macronutrient versus time restricted eating strategies (which by themselves have not shown to lead to sustained weight loss. but should be used in conjunction with everything else. let's not be one of those "no mortality benefit so i aint doing it" academic nihilists... such as the doctor who read the recent NEJM article stating time restricted intermittent fasting did not lead to a significantly different weight loss compared to caloric restriction alone and decided nahhhh doesn't work... and this physician has quite large waist circumference too. the point of the no mortality benefit so there is no point to doing it is suppose to refer to medications or invasive procedures that cost money and resources. Asking a patient to do something without such a cost to society and has no immediate downsides and possible benefit should not be dismissed so easily. There is no mortality benefit associated with using Mucinex and benzontate for a URI... yet people still prescribe it....) , and have a partner / family member who can support the plan.

Exercise regimen as if find a fitness trainer and really engage in exercise that gets the HR to a level to exceed anaerobic threshold.
I have done CPETs for obese individuals before (sometimes at the behest of the bariatric surgeon. there is some data regarding operative outcomes based on their VO2max) as well as to use their resting VO2 to calculate their RMR (for tailor a caloric strategy) and also an exercise prescription. There is a very nice website that can inform patients which physical activity they can do based on their highest METS. This way they do not get discouraged. MET Values for 800+ Activities - Golf - ProCon.org

Out of the clinical trials I have read (I read through the Columbia obesity course slides), it seems when an isolated intervention is test (which honestly is the proper way to run an RCT), none of these strategies seem to lead to sustained long term weight loss.

But no RCT (not even those done during those monthly long inpatient stays at Rockefeller University with a metabolic kitchen and also under room calorimetry) can properly capture real life successful stories and losing weight when one "throws the kitchen sink at weight management" and includes macronutrient diet restriction, time restricted eating, resistive exercise / weight lifting, aerobic exercise, pharmacotherapy, and possibly surgery (for the Class 3 and above BMI levels).

There is plenty of anecdotal data for patients with Class 3 obesity who "threw the kitchen sink"
Some state it is "expensive" to do so and only "rich people" can afford to do this and there is another instance of the socioeconomic divide.
Well.... there are plenty of youtube do it yourselfers who teach you how to eat healthy and wholesome on a budget ... while those may not be RCTs... we should not dismiss that advice so readily as physicians (especially if you a physician who is overweight yourself).
There is also 24 hour fitness... $10 a month (though they won't ever let you cancel lol) ...
So it's all a mindset.

What about those people who work and are busy? stuck in traffic? have to watch kids? do other stuff?

Buy some weights and put it in your home in your basement, If you are in an apartment, get some dumbells and barbells (tuck them away in the corner when not in use) and use them for a few sets few 5 minute interval. then go do something else then come back

there really is no excuse other than "i just dont feel like it."


but that pretty much highlights the crux of (what I think) Dr Metal is getting at. while the meds work wonderfully, they should not be the only tool. We need to throw the whole kitchen sink at the problem.

side observation .. I notice you did a CPET for a patient seen by bariatrics.... is that typical ask by your bariatric colleagues preoperatively?

also ive noticed that large groups of bariatric surgeons will recruit pulmonologist to be part of their practices... and ive always wondered why? Do you know why?

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[chessknt]

side observation .. I notice you did a CPET for a patient seen by bariatrics.... is that typical ask by your bariatric colleagues preoperatively?

also ive noticed that large groups of bariatric surgeons will recruit pulmonologist to be part of their practices... and ive always wondered why? Do you know why?

Ive never heard of this but the prevailing symptom of obesity is shortness of breath which is a problem relegated to pulmonologists (after cardiology has done a stress test/echo/LHC and farmed maximum procedures from the patient).

 

[NewYorkDoctors]

side observation .. I notice you did a CPET for a patient seen by bariatrics.... is that typical ask by your bariatric colleagues preoperatively?

also ive noticed that large groups of bariatric surgeons will recruit pulmonologist to be part of their practices... and ive always wondered why? Do you know why?

some literature is present for predicting mortality/morbidity outcomes with CPET VO2 cut off for ROUX EN Y

this is not directly applicable to gastric sleeve though as not studied for that surgery

but these patients tend to have dyspnea that is multifactorial so I usually like to get CPET anyway to discern their dyspnea further before just saying "oh yeah it's just your weight." I do not want to disparage or demean or belittle obese patients like that.

Additional info that could be found is PH, exercise induced bronchoconstriction to name a few.... but it can also confirm deconditioning or restriction from the obesity.

The VO2 number can be used by the surgeon however he/she wants to use it

OSA has to be diagnosed and treated first in this high prevalence population as one of the bariatric prerequisites so may as well have pulmonary available for evaluation.


Addendum: i'm not some woke-y body positive person. I just find it unhelpful to shame obese people as that "drives them into a hole moreso" and does not lead to any forward momentum in health progress. That leads them to the internet and they buy all kinds of quacky treatments that are meant to part them from their hard earned money. I can only hope to get patients out of the "futile cycle" that is Big Food and Big Pharma. A few patients (whom I can count on my hand's fingers) have taken the walk with a pedometer as many steps as you can break that record day by day and have lost and sustained significant weight loss. This along with a "healthy diet without processed foods but without a specific fad diet"

The key is no one likes to walk outside where bad things might happen (especially to older folk)
But the key I tell them is walk in circlesi ny our home. While you watch TV stand and hold your sofa and march in place. Get that pedometer up. Trick for "walking in place" is pedometer must be put into a side cargo pocket by the knees or else it does not pick up well on the waist for walking in place.

No one is doing an RCT on "walking in place with a pedometer" so please no snide academics in here saying "there is no evidence for that."

My evidence is I have done this myself for a year now while working 80+ doctoring job and I have 12% body fat (measured by bioimpedance) now. N= 1 sure
But all those youtube fitness people can't be wrong either?
Plus the N = 8 patients who followed by advice and dropped 10-20% of starting weight and metabolic syndrome and OSA are all better.

 

[NewYorkDoctors]

Ive never heard of this but the prevailing symptom of obesity is shortness of breath which is a problem relegated to pulmonologists (after cardiology has done a stress test/echo/LHC and farmed maximum procedures from the patient).

funny story I have been playing cardiologist for some of the primary care patients I oversee recently.
As alluded to in other posts, I have midlevels who help me see those patients. I get involved for anything and talk and examine patient for anything more than " fill out a form, give me a vaccine, draw my labs, order me a screening test, refill my meds that do not need titration."

for patients with dyspnea / chest pain, I have my midlevels get labs (calculate ACC/AHA risk score as well), 12 lead EKg at rest, order CXR and order PFTs done same day by my RTs. If something clear cut like asthma or COPD is present, then I focus on that first. If not and symptoms do not seem like intermittent asthma, I book them for echocardiography and CPET / EKG stress test.
in a few cases crushing substernal chest pain and concave up ST depressions over 1mm in 4 minutes of exercise - send to interventional cardiology and get that 99% mLAD opened up.

Other cases equivocal ST changes or nondiagnostic test poor effort with intermediate risk on ACC/AHA risk score - obtain prior auth for CT Coronary Angiography. Find nothing we're done. I'll manage the incidental lung nodules too.

Find non obstructive CAD refer to an academic cardiologist and then help manage the lipids BP and A1c from primary care

Find obstructive CAD, do that FFR-CTA part two then refer to interventional as needed.

That was not hard at all.

I invite a third part mobile ultrasound company that can do echocardiograms. They pay me a monthly rent stipend. it's useful to get a cardiologist to write the report and I have their portal images as well when working on PH cases.

why do I bother with all this? I would make more money just seeing more "bread and butter pulmonary consults" as that new consult with a quick PFT FENO 6MWT is faster and more value/time than doing all that above and then saying "nah not me."

Heck the mannitol challenge test (which saves a bit of time compared to methacholine) pays terribly and I often cannot get reimbursed for the mannitol (Aridol) which is about $100 a test kit. Yet i'll eat the cost and do the test in the right clinical situation
(which is rarely needed anyway... trial of bronchodilator / ICS did not help cough or dysypnea its probably not asthma anyway.... it's the army/navy/air force/ armed forces recruits that must get this test done)

Because I have had community cardiologists do ANNUAL NUCLEAR PERFUSION TESTS on patients who do not have coronary disease ...... yeah not with my patients.

 

[The kitchen sink]

some literature is present for predicting mortality/morbidity outcomes with CPET VO2 cut off for ROUX EN Y

this is not directly applicable to gastric sleeve though as not studied for that surgery

but these patients tend to have dyspnea that is multifactorial so I usually like to get CPET anyway to discern their dyspnea further before just saying "oh yeah it's just your weight." I do not want to disparage or demean or belittle obese patients like that.

Additional info that could be found is PH, exercise induced bronchoconstriction to name a few.... but it can also confirm deconditioning or restriction from the obesity.

The VO2 number can be used by the surgeon however he/she wants to use it

OSA has to be diagnosed and treated first in this high prevalence population as one of the bariatric prerequisites so may as well have pulmonary available for evaluation.


Addendum: i'm not some woke-y body positive person. I just find it unhelpful to shame obese people as that "drives them into a hole moreso" and does not lead to any forward momentum in health progress. That leads them to the internet and they buy all kinds of quacky treatments that are meant to part them from their hard earned money. I can only hope to get patients out of the "futile cycle" that is Big Food and Big Pharma. A few patients (whom I can count on my hand's fingers) have taken the walk with a pedometer as many steps as you can break that record day by day and have lost and sustained significant weight loss. This along with a "healthy diet without processed foods but without a specific fad diet"

The key is no one likes to walk outside where bad things might happen (especially to older folk)
But the key I tell them is walk in circlesi ny our home. While you watch TV stand and hold your sofa and march in place. Get that pedometer up. Trick for "walking in place" is pedometer must be put into a side cargo pocket by the knees or else it does not pick up well on the waist for walking in place.

No one is doing an RCT on "walking in place with a pedometer" so please no snide academics in here saying "there is no evidence for that."

My evidence is I have done this myself for a year now while working 80+ doctoring job and I have 12% body fat (measured by bioimpedance) now. N= 1 sure
But all those youtube fitness people can't be wrong either?
Plus the N = 8 patients who followed by advice and dropped 10-20% of starting weight and metabolic syndrome and OSA are all better.

The CPET catches PH, that a resting echo does not , which then confirmed by RHC?

 

[The kitchen sink]

funny story I have been playing cardiologist for some of the primary care patients I oversee recently.
As alluded to in other posts, I have midlevels who help me see those patients. I get involved for anything and talk and examine patient for anything more than " fill out a form, give me a vaccine, draw my labs, order me a screening test, refill my meds that do not need titration."

for patients with dyspnea / chest pain, I have my midlevels get labs (calculate ACC/AHA risk score as well), 12 lead EKg at rest, order CXR and order PFTs done same day by my RTs. If something clear cut like asthma or COPD is present, then I focus on that first. If not and symptoms do not seem like intermittent asthma, I book them for echocardiography and CPET / EKG stress test.
in a few cases crushing substernal chest pain and concave up ST depressions over 1mm in 4 minutes of exercise - send to interventional cardiology and get that 99% mLAD opened up.

Other cases equivocal ST changes or nondiagnostic test poor effort with intermediate risk on ACC/AHA risk score - obtain prior auth for CT Coronary Angiography. Find nothing we're done. I'll manage the incidental lung nodules too.

Find non obstructive CAD refer to an academic cardiologist and then help manage the lipids BP and A1c from primary care

Find obstructive CAD, do that FFR-CTA part two then refer to interventional as needed.

That was not hard at all.

I invite a third part mobile ultrasound company that can do echocardiograms. They pay me a monthly rent stipend. it's useful to get a cardiologist to write the report and I have their portal images as well when working on PH cases.

why do I bother with all this? I would make more money just seeing more "bread and butter pulmonary consults" as that new consult with a quick PFT FENO 6MWT is faster and more value/time than doing all that above and then saying "nah not me."

Heck the mannitol challenge test (which saves a bit of time compared to methacholine) pays terribly and I often cannot get reimbursed for the mannitol (Aridol) which is about $100 a test kit. Yet i'll eat the cost and do the test in the right clinical situation
(which is rarely needed anyway... trial of bronchodilator / ICS did not help cough or dysypnea its probably not asthma anyway.... it's the army/navy/air force/ armed forces recruits that must get this test done)

Because I have had community cardiologists do ANNUAL NUCLEAR PERFUSION TESTS on patients who do not have coronary disease ...... yeah not with my patients.

I see your practice is big on CPETs, how many do you run daily? Any recs on a solid machine/manufacturer?

 

[NewYorkDoctors]

The CPET catches PH, that a resting echo does not , which then confirmed by RHC?

Well . I don’t always have access to a tte before a cpet . If cardiology refers me a patient and sends me an echo and rvsp is not too impressive then my doing a cpet when PFTs and FENO are not too impressive is invariably doing to find de conditioning most of time .

If no echo was done before and cpet turns out to have no cardiovascular or pulmonary vascular limitation pattern then I can be justified in not ordering a formal echo. I mean I can take a “feee non billed “ look with my own point of care ultrasound probe if I were that concerned

As many cases of dyspnea are deconditioning at the end of the day , I’ve found cpet useful to affirm “it’s a big nothing burger you need to get more steps in . Here get a pedometer .” It helps provide reassurance to patients that they can “push past that exercise barrier.”

Or else they are getting nuc,d ,CT scanned , and cathed nonstop …

This “exercise induced PH” which I believe is not in the latest ers PH guidelines anymore was once thought to be a precursor to PAH and is managed similarly to PAH. Technically yes a situation may arise in which a patient has a fairly normal resting echo but exercise would find the PH pattern (and imaging has no ILD) but that diagnosis would be best established with invasive cpet at a center of excellence .


I have done 226 cpets since I started in 1/2023

A handful were my own to measure my AT and Vo2 as I continued working out and running to track my own progress . Let’s say I’m no elite athlete but I finally > 85% predicted vo2 and AT at > 50% of vi2max now . Yay .

It doesn’t pay a spectacular amount . 94621 pays about the same as a pft but takes way longer to do .

It makes more money just running pft after pft . But I get so many “I’m still short of breath !!”
It’s helpful of get proof nothing organic is preset and one can pursue exercise or mental health and knowing nothing was missed like PH or EIB.
(You’d be surprised how many patients refuse to do a bronchodilator challenge without “proof”)

Also cpet is useful when cardiologist sends me an intermediate pasp and TRV in echo patient . There is no evidence of class 2 . So while. I do PFTs , CxR (Ct indicated ) and sleep study , I usually would do cpet as well to give more confidence in doing VQ scan and asking for RHC
If I see normal vo2 , normal vdvt , normal ve/veco2 / no desat then I’m less inclined to ask for rhc

I use the vyntus cpex system . Rather pricey but rock solid reliable.


Addendum:

I am seldom asked by thoracic surgery for CPET prior to thoracic surgery unless the patient's ppoFEV1 or ppoDLCO are under 30%.
In those cases I do CPET up front after PFTs are done as soon as possible (same day if no one is on the schedule)
For those ppo 30-60%, I cannot for the life of me find a proper protocol for stair climb test or shuttle walk test. The latter seems really difficult to find that "audio ping" recording and seems impossible to standardize. Needless to stay I'm not sure of my thoracic colleagues would accept any "stair climb test" or "incremental shutle walk test" that I might try to do.

Still I might to find a protocol as there is that subset of patients who have ppo 30-60% but bad joints and cannot pedal a bike.
I just dont have enough real estate to do those things where I am at other than in the basement garage. hmmm something to think about i guess

But even those are fairly infrequent.

Most CPET i do is for dyspnea that ultimately becomes "deconditioning." I'm sure this is the case for all CPET labs

In the cases in which I "get the first shot at dyspnea," I have identified cardiac etiologies and PH before any echos or nuc's are done. But that is the exception and not the rule.

 

[The kitchen sink]

Well . I don’t always have access to a tte before a cpet . If cardiology refers me a patient and sends me an echo and rvsp is not too impressive then my doing a cpet when PFTs and FENO are not too impressive is invariably doing to find de conditioning most of time .

If no echo was done before and cpet turns out to have no cardiovascular or pulmonary vascular limitation pattern then I can be justified in not ordering a formal echo. I mean I can take a “feee non billed “ look with my own point of care ultrasound probe if I were that concerned

As many cases of dyspnea are deconditioning at the end of the day , I’ve found cpet useful to affirm “it’s a big nothing burger you need to get more steps in . Here get a pedometer .” It helps provide reassurance to patients that they can “push past that exercise barrier.”

Or else they are getting nuc,d ,CT scanned , and cathed nonstop …

This “exercise induced PH” which I believe is not in the latest ers PH guidelines anymore was once thought to be a precursor to PAH and is managed similarly to PAH. Technically yes a situation may arise in which a patient has a fairly normal resting echo but exercise would find the PH pattern (and imaging has no ILD) but that diagnosis would be best established with invasive cpet at a center of excellence .


I have done 226 cpets since I started in 1/2023

A handful were my own to measure my AT and Vo2 as I continued working out and running to track my own progress . Let’s say I’m no elite athlete but I finally > 85% predicted vo2 and AT at > 50% of vi2max now . Yay .

It doesn’t pay a spectacular amount . 94621 pays about the same as a pft but takes way longer to do .

It makes more money just running pft after pft . But I get so many “I’m still short of breath !!”
It’s helpful of get proof nothing organic is preset and one can pursue exercise or mental health and knowing nothing was missed like PH or EIB.
(You’d be surprised how many patients refuse to do a bronchodilator challenge without “proof”)

Also cpet is useful when cardiologist sends me an intermediate pasp and TRV in echo patient . There is no evidence of class 2 . So while. I do PFTs , CxR (Ct indicated ) and sleep study , I usually would do cpet as well to give more confidence in doing VQ scan and asking for RHC
If I see normal vo2 , normal vdvt , normal ve/veco2 / no desat then I’m less inclined to ask for rhc

I use the vyntus cpex system . Rather pricey but rock solid reliable.


Addendum:

I am seldom asked by thoracic surgery for CPET prior to thoracic surgery unless the patient's ppoFEV1 or ppoDLCO are under 30%.
In those cases I do CPET up front after PFTs are done as soon as possible (same day if no one is on the schedule)
For those ppo 30-60%, I cannot for the life of me find a proper protocol for stair climb test or shuttle walk test. The latter seems really difficult to find that "audio ping" recording and seems impossible to standardize. Needless to stay I'm not sure of my thoracic colleagues would accept any "stair climb test" or "incremental shutle walk test" that I might try to do.

Still I might to find a protocol as there is that subset of patients who have ppo 30-60% but bad joints and cannot pedal a bike.
I just dont have enough real estate to do those things where I am at other than in the basement garage. hmmm something to think about i guess

But even those are fairly infrequent.

Most CPET i do is for dyspnea that ultimately becomes "deconditioning." I'm sure this is the case for all CPET labs

In the cases in which I "get the first shot at dyspnea," I have identified cardiac etiologies and PH before any echos or nuc's are done. But that is the exception and not the rule.

Ok I got it, makes sense

You mention you sometimes see pHTN , EIB in your formerly ‘undifferentiated’ dyspnea pateints with variable prior work ups. And a large majority come back with deconditioning. I noticed the same while doing CPETs in my institution as well , however we refer them out at my current institution.

When i was in fellowship we use to get a ton of heart failure referrals with cardiac limitations … that and deconditioning

 

[NewYorkDoctors]

right i got it initially to help out the thoracic surgeons I work with.
But I have found that they seldom need this test done.
As mentioned above I will get it done if the ppoFEV1 and DLCO are under 30 as per guidelines
in a few situations in which the CPET changed management was in a patient who was otherwise high risk. ppoDLCO < 30%. VO2max was 13.4 and VE/VCO2 was 38 in a nav bronch EBUS diagnosed stage 1B squamous cell lung cancer in an 84 year old man. thoracic initially declined. but after getting perfusion scanning and finding most of that tumor occupied a lobe that was only contributing about 5% of that right lung and a much more palapatble ppoVO2 value, decision was made for sublobar resection after finishing neoadjuvant chemo. that patient is doing pretty well all things considered.

for that 30-60% group, the surgeons often just do a more limited resection or do neoadjuvant chemo first and proceed anyway. they appreciate the CPET data but never really ask for it.



who says only nephrologists do arithmetic. lol. don't forget the other half of acid base is respiratory.


also the Vyntus CPEX is quite costly. final cost with shipping and all was about $66,000.
the 200+ CPETS i have done have not covered the cost at all.
assuming $150 per 94621 (approximate in dollar amounts rather than RVUs), then I am nowhere near that am ount yet.
plus those digitable volume transducers run $10 a pop and a PFT mouthpiece ($1-3 depending on which brand) have to be used during the initial spirometry/MVV portion of the CPET.
not to mention the RT who does the test with me gets a "cut" of that (goes to paying salary)

I own my own shop (with a large tertiary care center with all the superspecialists a few blocks away) so I can eat the cost and be fine with it knowing I am "providing a service" For my patients

but I can see how most systems that have administrators to feed will not want to sink costs into a CPET.

PFTs (especially by body box pleth - for those that are wondering if a patient messes up the nitrogen washout lung volume technique they have to WAIT 20 minutes before trying again) can be run back to back. 5 minutes for someone who is "with it." 10-15 for someone who is not perhaps

A CPET from hooking up the EKG reads, calibrating the system, rest phase, warm up phase, exercise 10 minutes or more, recovery phase 6 minutes or more, take the patient off, give patient a towel, water, and snacks... may take one hour.


I would like to think doing so many PFTs pays for the CPET. but a hungry troll (administrator) may not see it that way