The Specialty of Bariatrics in Florida: Update 2000

By William C. Dudney III, M.D.

Editor’s Note: An article similar to this was originally published in a 1997 issue of The Bariatrician. Since then a number of important actions have occurred: the fen/phen controversy, the Florida Board of Medicine’s regulations on obesity treatment, and the AMA’s stance on vitamin and supplement sales. This article, although focused on the State of Florida, provides food for thought for bariatricians regardless of practice location. The author is a past president of the Florida Society of Bariatric Physicians and has just completed a term as a member of ASBP’s Board of Trustees.

"How I Do It In My Bariatric Practice" is a regular journal feature which affords readers the opportunity to share their clinical experiences and observations from their bariatric practices. As is the case with all material in The Bariatrician, the ASBP will not endorse or recommend any therapeutic protocol for the treatment of obesity and the thoughts, opinions and observations, as well as any anecdotal material presented in this feature, will not represent the ASBP policy. In addition, the views and opinions expressed by the author(s) in this feature will not or do not necessarily reflect the view of the American Society of Bariatric Physicians, its board or trustees, or any member of the editorial or professional staff of the ASBP headquarters office.

All members are encouraged to submit articles for this feature, and as with all other clinical articles or practice management/business articles submitted by our members, we will pay a $300 honorarium for accepted manuscripts.

Introduction

Bariatrics is a separate medical specialty treating a special patient population with a multimodal approach which often includes use of prescription medication. As bariatrics is not yet a formally recognized specialty under the auspices of the American Board of Medical Specialties, no organized residency program exists. This is unlikely to change, as the current political climate associates specialization with increased costs and increased utilization. No "new" specialties will be recognized until the current wave favoring primary care has passed. Bariatricians, therefore, learn clinical skills from a variety of sources, including the medical literature, but also lean heavily on the experience of colleagues and organized specialty society meetings such as those sponsored by ASBP. Because bariatricians are "different" from other specialties, our use of medications may seem "different" or peculiar or "off-label" in ways not understood by other practitioners, academic experts or legislative watchdogs.

By forming together and acknowledging these similarities and differences, Florida bariatricians can avoid misunderstandings and well-meaning criticism of our usual and customary methods or patient treatment. Florida bariatricians strongly support the medical board and regulatory agencies in attempts to recognize local standards of care and protect the public from unsafe or unethical medical practitioners.

I believe the following information shows how bariatrics should actually be practiced in Florida after the latest round of regulation.

Several sources provide treatment guidelines for using medications to achieve weight loss. Thankfully, all these published guidelines are the result of committee action and thus have broad applicability. But a bariatrician wants to know specifically: "How do I do this, and how do I do it right?" For specific practice tips, general guidelines seem to be lacking something, a bit like kissing your sister. As a full-time bariatrician in Florida, I am sharing a list of what I and many of my colleagues actually do. This list of clinical points, as a single doctor’s professional opinion, has the poetic license to be very specific, and still offer some areas of general clinical agreement to serve as a foundation for standards of care.

Age of Patients

Anorexiant medication should be reserved for patients over the age of 18. The rare teenager who is considered for drug therapy should have parental support and permission and must be exceptionally motivated and reliable to prevent redistribution of appetite suppressants to friends and peers. Parents must be willing and able to control possession of the drug bottle.

Use of medication in prepubertal children is outside current reasonable standards. The older patient age limit is unknown, but it is common for bariatricians to treat patients in their 60s and early 70s.

Size of Patients

Use of appetite suppressants in "thin" or "normal" weight patients is a confusing issue. Like the desired size of one’s nose, this is a cosmetic gray area that seems to torpedo rigid criteria, such as the need for a body mass index (BMI) of 30 or 27 in the presence or co-morbidities for treatment eligibility. If medication can be prescribed for maintenance to hold the weight of a patient who has achieved "normal" or "thin" weight, can medication be used to hold the weight of a patient who comes in already "thin" or "normal weight?" This is the guiding principle – the bariatrician should never use medication to help a patient achieve an unhealthy or unrealistic weight.

The Florida Board of Medicine has now established rules for entrance weight. Therefore, physician notes should include documentation of the patient’s height and weight for BMI calculations (27 with risk factors, 30 without) or body fat calculations (Male greater than or equal to 25%, female greater than or equal to 30% fat). A bariatrician whose practice includes large numbers of patients falling below these parameters is not practicing in a style that is typical of mainstream bariatric medicine.

Frequency of Visits

A doctor-patient relationship must be established and must continue as long as medication is prescribed. The Florida medical board requires the physician to personally review the patient’s record before a prescription for appetite suppressants can be written – a re-evaluation within four weeks, and follow-up visits at no longer than three-month intervals. Traditional bariatrics care usually involves more frequent visits than required by the board, i.e. monthly.

If the doctor uses physician extenders, medication changes and/or dispensing actions require the doctor’s actual presence in the office, as these acts cannot be delegated to others. In Florida, the initial prescription for appetite suppressants cannot be "phoned-in." All of the rules still apply even if the medication is not a controlled substance, such as orlistat.

Laboratory Work-Up

A balance between cost and need is present, but minimal labwork should include the executive-type chemistry and lipid panel, CBC, and TSH. EKGs, pre- and/or post-medication, may be indicated in selected patients, but the routine use of EKGs as a substitute for the physician’s stethoscope, pulse palpation and cardian history is not the standard of care for quality bariatrics.

Drug Combinations

The fen/phen controversy is behind us, and patients’ deadlines for participation in the national settlement was March 2000. Media ads from law firms have intentionally misled some patients into believing that exposure to fen/phen in the past will result in a financial windfall, if only they will contact the advertising law firm; failure to do so will leave the cash on the table. The fine print is that the patient must have proven significant value damage to be eligible for cash, and, since not many patients have significantly abnormal echocardiograms, the aim of the attorney’s ads may be to recruit patients who will "opt out" of the national settlement and allow the law forms to pursue separate settlement amounts.

In terms of the common clinical situation of a patient who comes in for bariatric treatment seeking an appetits suppressant but is already on a serotoninergic drug (or in meed of one), the Florida Board of Medicine rules now state that only drugs approved by the FDA for the indication of weight loss can be prescribed for weight loss – the Meridia loophole clause. If a patient is on Prozac, for example, the Prozac must be prescribed for an indication other than weight loss. Experience has shown bariatricians that combinations can be more effective than single drug treatment, just like any other medical specialty. The combination of appetite suppressants and serotonin agents does require vigilance for the serotonin syndrome.

Diuretics

Diuretics are not used to cause weight loss. The art of diuretic use in bariatrics takes into consideration that our patient population includes many overweight women who are concerned about their appearance and complain of bloating, puffiness, menstrual discomfort, swollen hands and feet, tight rings and shoes, and, because of a subjective sensation of water retention, have difficulty complying with instructions to drink more fluid. Low dose, prn, or alternate day diuretic therapy often improves patient comfort and compliance and can reduce the risk of elevated blood pressure from sympathomimetics. Diuretic use does dictate prudent electrolyte management and lab follow-up at regular intervals.

Thyroid Medications

Bariatricians may prescribe thyroid, but thyroid preparations are not indicated to cause weight loss. The consideration of thyroid replacement therapy in patients with borderline or subclinical hypothyroidism is a common clinical problem in bariatrics. The bariatric patient population includes many with classic hyperthoid symptoms, positive family history of response to thyroid medication in the past. Some of these patients will have TSH levels well above normal, and others will have only borderline elevation. The decision to treat or not requires the usual good doctor-patient dialogue. Thyroid medication is not used to initiate weight loss in patients with normal endocrine status.

Charting

Bariatricians tend to develop "routines" as the same types of patients are seen day after day. Such routines may result in brief or oddly coded notes. The good bariatrician will avoid being lulled into sloppy charting and, at every visit, review each case for response and side effects and plan for continuing care. A S.O.A.P style note or some similar method is preferred. If abbreviations unique to the doctor’s practice are used, a readily retrievable in-house abbreviation list should be available to translate the notes.

Maintenance Medication

Bariatricians commonly keep some patients on maintenance medication for months or years, in spite of the PDR 12-week guideline for phentermine, phendimetrazine and diethylpropion. Maintenance is a plan that has a beginning, and end, and a follow-up in the medical record that documents the plan. This plan should include not only medication, but appropriate diet and exercise instruction. Maintenance is not done if the medications are ineffective or if the patient is drug-seeking for a mood altering effect.

Vitamin and Nutritional Supplements

There is some risk that dieting patients may not take in enough quantity or types of food to achieve recommended daily allowance values of nutrients. For this reason, various types of multi-vitamin and mineral supplements are often prescribed. Appetite suppressants can raise the metabolic rate, and increased metabolic rate is further justification for increased vitamin intake.

The bariatrician should not make excessive or unrealistic claims for vitamin therapy, however. As these substances are "foods" rather than "drugs," the medicolegal restrictions are different and the ethics of good medical practice should guide their use. The rule of thumb is that a bariatrician is first and foremost a physician treating patients, not someone whose primary concern is commissioned vitamin sales.

The AMA’s recent statement that members cannot ethically sell products such as supplements is inconsistent with established and ethical bariatric practice. The resolution of this conflict will require political compromise, as the recent AMA rules are felt by some to be knee-jerk over-reactions to undo the Sunbeam fiasco.

The Bariatrician - Fall 2000, pgs 26-28