COURSE VIDEOS

THE HUNGRY BRAIN

In this class we review the physiology of hunger. Energy balance is regulated by a complicated mechanism within the brain, the gut and the body stores (fat and muscle and glucose). There is a hormonal “dance” that occurs every minute in the body. Hunger and satiety is regulated by both the “metabolic” brain and the “hedonistic” brain. This is of course a function of the hypothalamus and the mesolimbic system respectively. The focus of this talk is to guide you through this part of THE HUNGRY BRAIN with an eye towards how this physiology plays a role in treatment. The talk begins with a focus on the hypothalamus, specifically the arcuate nucleus and the mesolimbic system.

THE HUNGRY BODY

This “class” continues on the physiology of hunger and satiety and energy balance in the body. It expands on the brain’s role of energy balance and includes a review of the peripheral hormones involved in food intake and food storage. Essentially energy balance involves a communication between brain, gut and body storage. This communication occurs as a result of dozens of hormones being secreted sending messages to the organs involved in order to regulate food intake, satiety, energy storage. Having explored the role of the metabolic and hedonic brain in this process we move to the gut and the storage systems (as I call it- the GUT and the BUTT). In this we review the role of gut hormones such as:

1. GLP-1, PYY, CCK at the level of the gastrointestinal tract (among others)
2. Leptin and adiponectin at the level of fat tissue
3. Glucagon and insulin at the level of glucose stores
4. Myosin at the level of muscle tissue

This allows for a physiological basis of learning as to why certain treatments are effective in obesity management. By understanding how the gut and brain and storage work (or don’t) we can then explore why for example certain medication and/or bariatric surgery would be so effective in the treatment of obesity.

MOTIVATIONAL COMMUNICATION 

WHY DON’T PATIENTS DO WHAT WE TELL THEM TO DO? This series of videos attempts to cover the basics in how to talk to patients effectively in a chronic disease setting. Let’s face it- we were trained in the language of acuity. Most of our clinical training from school to residency and beyond was done in an acute care environment and yet every day much of our practice revolves around our ability to manage chronic disease. Obesity is indeed such a chronic disease. It is never cured; it is managed. And so our ability to speak the language of CHRONICITY is crucial to our effectiveness in this area of clinical practice. The key to mastering this technique is indeed motivational communication.

The principals behind motivation interviewing and motivational communication are that the therapeutic relationship should be a partnership between patient and clinician whereby the clinician works WITH the patient to resolve ambivalence and explore the motivation and action towards behavioural change. Motivational interviewing (or Motivational Communication) was initially described by Dr. William Miller in the early 1980’s and was established initially through the practice of addictions counselling. It indeed has had a significant growth in a variety of fields including chronic disease management. There are thousands of papers that have been published in support of the use of this technique showing that not only does it HELP in clinical outcomes such as adherence and compliance but that directive care (the old way of doing things) can indeed be harmful. MI acknowledges that every patient has a pace and everyones motivation for change in personal. It indeed sees the patient as the ultimate decision maker. Some of the techniques we will explore in this “class” are key to learning and practicing MI including:

Resolving ambivalence
Rolling with Resistance
Eliciting

Some key skills we will focus on involve:

1.     Reflective Listening
2.     Eliciting change talk
3.     Patient Engagement
4.     Establishing Empathy
5.     Action planning

These are broken down in a series of videos in order to make the process easier to learn and the learning more focused. You can go back and forth between the videos as you see fit to refresh your skills.

PHARMACOTHERAPY

We offer patients medications for every other disease. We diagnose hypertension and reach for any one of a number of therapeutic options. The same can be said for diabetes, dyslipidemia, depression. In obesity we tell patients to work harder, eat less, move more. NO MORE. This complex physiological mismatch deserves modern day medicine in its therapeutic approach.

We review the history of pharmacotherapy for obesity from previous to present day. We take a physiological first principals approach to why these drugs work and look at the studies behind them. From mechanisms of action to clinical studies we will review the pharmacological “tool kit” available to you. This class also offers practical tips to titrating medications and even the idea of “stacking drugs” (multiple medications stacked together).  

BARIATRIC SURGERY

This indeed is a metabolic surgery. We review the physiology of obesity in the context of the neurohormal response between the gastrointestinal tract and the brain. In this context we show how bariatric surgery can be so effective for both treatment of obesity and its complications. We explore the process of bariatric surgery from the concept to the clinical. We explain the surgical approach to sleeve gastrectomy and roux en y gastric bypass and what is required on the clinical level. We then turn to how to screen patients for bariatric surgery.

1. Who qualifies for surgery?
2. What are the in the indications for surgery?
3. What are the contraindications for surgery?
4. How do we screen patients for surgery?
5. How do we prepare patients for surgery?
6. What should the process of preparation look like?
7. What should follow up post surgery look like?
8. What are the complications post surgery in the short term and in the long term?
9. How to address these complications in our practices?

This class aims to address these issues and provide a clinical framework for them.

WEIGHT BIAS

This is the last prejudice in medicine. Studies show that 80% of patients have been shamed by their physicians for their weight. Weight bias can be explicit or implicit in practice; obvious or subtle. Regardless the implications cause harm to patients medically, physically and psychologically. We push patients away from getting the care they need and we imply that their disease is their fault. We force them to self manage. This would never occur in any other disease model. In this class we explore ever growing evidence about the prevalence and effect of weight bias in medicine and in society and how to counter it in your practice. We should you how to create the ultimate SAFE SPACE for patients and how to move the conversation forward. Weight bias has NO place in medicine. It undermines our clinical credibility and our professional integrity. When we know better, we do better. Let’s work towards that.

BINGE EATING DISORDER 

This is the most common eating disorder in medicine. It affects more than 2% of the population worldwide. Binge eating disorder is a compulsive overeating phenomenon where a person eats more than what others do in a confined period of time even without hunger with a compulsion to continue and an inability to stop. It is rooted in physiology involving the mesolimbic system which is responsible for compulsion and reward. It is mediated through pathology in the ventral striatum and nucleus accumbent and involves dysfunction of dopamine release and opioid receptors. It is estimate that 30% of patients who present for obesity management will have BINGE EATING DISORDER (BED), while 70% of people with the disease will not have obesity.

Let’s be clear. Obesity is an endocrinopathy with psychological and metabolic complications.Binge Eating Disorder is a psychopathology with metabolic consequences. The two diseases may share a space but one does not cause another and they should be treated differently. There are a variety of treatment options including pharmacotherapy and cognitive behavioural therapy. We highlight the pathophysiology of this disease, the clinical manifestations for it. We will give you practical screening for BED and the evidence behind treatment.