christopher still, do - geisinger health system
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Obesity Management
Continuum of Care:Wellness to Bariatric Surgery
Christopher Still, DO, FACN, FACPDirector, Center for Nutrition & Weight Management
DSL#06-0486 ©2006
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Why all the Interest in Obesity Treatment?
Why all the Interest in Obesity Treatment?
• Discovery of “obesity genes”
• Management: Medical / Surgery
• Epidemic*
• Discovery of “obesity genes”
• Management: Medical / Surgery
• Epidemic*
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More Than One Half of US Adults Are Overweight or
Obese
12.8% 14.1% 14.4%
22.3%
33%
0
10
20
30
40
50
60
70
80
US
Po
pu
lati
on
Ag
e 20
+ (
%)
1960-1962NHES
1971-197NHANES I
1976-1980NHANES II
1988-1994NHANES III
2003NHANES
Overweight or Obese US Adults
BMI 25 - 29.9BMI 25 - 29.9 BMI BMI 30 30
NHLBI. Obes Res. 1998;6(suppl 2):51S-209S.Flegal, et al. Int J Obes. 1998;22:39-47.
43.3%43.3% 46.1%46.1% 46.0%46.0%
55.0%55.0%
63%63%
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Obesity Defined by Body Mass Index (BMI)
Healthy: 20-24.9
Overweight: 25-29.9
Obese: 30-39.9
Morbid Obese: 40+
BMI = Weight (kg)/Height (m2)
Behavioral Risk Factor Surveillance System, CDC
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• Fastest-growing subset with an increased prevalence of 62% between 1994 – 2000
• Approximately 10 million Americans are morbidly obese (4.7% of the adult population)
Morbid Obesity
www.asbs.orgTrust for America’s Health Facts 2004
http://www.cdc.gov/pcd/issues/2005/jan/04_0087.htm
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2.52.5
2.02.0
1.51.5
1.01.0
002020 2525 3030 3535 4040
BMIBMI
Mor
talit
y R
atio
Mor
talit
y R
atio
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ModerateRisk
VeryLow Risk
Low Risk
ModerateRisk
High Risk
VeryHigh Risk
MenMenWomenWomen
Digestive andpulmonary disease
Cardiovascular andgallbladder diseaseDiabetes mellitus
Obesity and Mortality Risk, 1989
Obesity and Mortality Risk, 1989
1 Adapted with permission from Gray DS. MedClin North Am. 1989;73:1
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• Abnormal PFTsPulmonary disease
• Obstructive sleep apnea• Hypoventilation syndrome
Gall bladder disease
• PCOS
Gout
Stroke
• DiabetesCardiovascular disease
• Hyperlipidemia• Hypertension
• Insulin resistance syndrome
• Breast, uterus, cervixCancer
• Colon• Prostate
• SteatosisLiver disease
• NASH• Cirrhosis
Phlebitis
Medical Co-Morbidities
Osteoarthritis
PCOS = polycystic ovarian syndrome
NASH = nonalcoholic steatohepatitis
NIH/NHLBI. September 1998; NIH publication no. 984083.
Gynecologic/Urologic abnormalities• Abnormal menses• Infertility
• Stress incontinence
Premature Death
Depression
GERD
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“Right behind this obesity epidemic is a diabetes epidemic,
and that’s very expensive.”
• 9 out of 10 people newly diagnosed with Type 2 Diabetes are overweight
• Direct medical expenditures incurred by individuals with diabetes $13,243 vs. $2,560 for person without diabetes
Wolf AM, Colditz GA. Current estimates of the economic cost of obesity in the US. Obesity Research. 1998 6(2):97-106. Pories WJ, et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus.
Annals of Surgery. 1995; 222(3):339-352. http://www.diabetes.org/DiabetesCare/1998-02/pg296.htm
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The Cost of Obesity Compared to other Chronic Diseases
$ Billions
Obesity 1 75.0Type 2 Diabetes 2 73.7Coronary heart disease 352.4Hypertension 4 28.2Arthritis 5 23.9Breast Cancer 6 7.1
1 Finkelstein EA, Obes Res 2004;12 4. Hodgson TA et al. Med Care 2001;39:599 2 ADA Diabetes Care, 2003;26:917 5 Yelin & Callahan. Arthritis Rheum 1995;38:13513 Hodgeson TA et al. Medical Care 1999:37:994. 6Brown ML, et al. Medical Care; 2002;40(suppl): IV-104
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“Obesity harder on health than smoking.” Reuters Health 03/13/2002
• Obesity raises individual:
– Healthcare costs by 36%
– Medication costs by 77%
RAND/UCLA study
• Smoking raises individual:
– Healthcare costs by 21%
– Medication costs by 28%
Sturm, Roland. The effects of obesity, smoking and drinking on
medical problems and costs. Health Affairs 21(2): 245-253
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Economic Cost of Obesity: Employer costs
Total cost to US employers estimated at $13 billion/year:• $8 billion in health insurance• $2.4 billion in paid sick leave• $1.8 billion in life insurance• $1 billion in disability insurancePrevention Makes Common Cents: Estimated Economic Costs of Obesity to U.S. Business, DHHS,2003
Associated annually with:
• 39 million lost work days• 239 million restricted-activity days• 63 million physician visits• 89 million bed-daysNBGH (Institute on the Costs and Health Effects of Obesity)
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Thompson, D.et al. Am J Health Promot 1998;12:120-127
Percent Unable to Work9.6
5.65.9
12.6
7.9
4.7
Healthy Weight Overweight Obese
Men Women
Obesity: Greater Rates of Disability
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Consequences of ObesityAre Devastating
risk of morbidity and mortality1,2
Risk factors
health costs to– Patient– Healthcare system
workforce productivity3
absentee rates employer costs (5%)
1Pi-Sunyer FX. Am J Clin Nutr. 1991;53(suppl 1):1595S.2Calle EE et al. N Engl J Med. 1999;341:1097.
3Thompson D et al. American Journal of Health Promotion. 1998;13:120.
WellnessWeight/Medical Management
Bariatric Surgery
How Is Obesity Treated?
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Components of an Effective Obesity Management
Program
Wadden TA, Foster GD. Behavioral treatment of obesity. Med Clin North Am. 2000;84:441-461
Stumbo, PH, et. al. Dietary and medical therapy of obesity. Surg Clin N Am 85(2005)703-723
Diet
PhysicalActivity
BehaviorModification
Medicationsor
Surgery
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• Standardized meal plans instructed by RDs– 1200 – 1500 Kcal, 25% - 30% fat– 1500 – 1800 Kcal, 25% - 30% fat– ADA (food exchanges) diabetes, PCO, etc.
• Daily food logs journal• Weekly weigh-in• “Occurrence” exercise program• Water intake• Behavior modification lessons• Pharmacotherapy if weight loss plateaus• Bariatric surgery after comprehensive process
Medical ManagementTreatment Plan
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Diet and Physical Activity
Pavlou KN, et al. Am J Clin Nutr. 1989;49:115-1123
ExerciseNonexercise
Balanced caloric deficit dietProtein-sparing modified fast
0-0-
2-2-
4-4-
6-6-
8-8-
10-10-
12-12-
14-14-
16-16-
1 2 3 4 5 6 7 8 9 10 11 121 2 3 4 5 6 7 8 9 10 11 12 3030
Treatment (wk) Follow-up (mo)
Weig
ht
loss
/gain
(kg
)
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Weight Loss Medications
sibutramineMeridia1
orlistatXenical2
phentermine Adipex3
Average Weight Loss at
1 yr
4.5 kg (9.9#) 2.59 kg (5.7#) 3.6 kg (7.92#)
Concerns monitor b/p GI symptoms monitor b/p
Epocrates Rx Online. San Mateo (CA): Epocrates, Inc. 2003-(cited 2006 Jan 23). http://www2.epocrates.comZhaoping Li, MD, PhD, et. al. Meta-analysis: Pharmacologic Treatment of Obesity. Ann Intern Med. 2005;142:532-546.
1Knoll Pharmaceutical Company. 2 Roche Group. 3 Phentermine (generic)
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Success Rate of Various Weight Loss Treatments
• Conventional (obese)
Diet
ExerciseBehavior ModificationAnti-Obesity Drugs
• Surgical Therapy (MO)
Weight Loss Surgery
95% to 98% failure rates of sustained weight loss in obese population at 5 yrs
99% failure of sustained weight loss for the morbidly obese population
50% success rate at 16 years
http://www.nhlbi.nih.gov/guidelines/obesity/practgde.htm accessed 5 February 2006 Rosenbaum M, Leibel RL. Obesity: Medical Progress. NEJM 1997; 337:396-407.
Buchwald, H et. al. Bariatric Surgery A Systematic Review and Meta-analysis. JAMA 2004; 292:1724-1737
Bariatric (Obesity) Surgery
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Why Surgery?
• Works when all other therapies fail• Resolves co-morbidities• Standardization of procedures• Risk: surgery < maintain morbidly
obese
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0.68%
6.17%
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
BARIATRIC* CONTROLS
MO
RT
AL
ITY
* Includes peri-operative (30-day) mortality of 0.4%p-value 0.001Christou (McGill University, Montreal, Canada)
Implication of not managing morbid obesity
89% REDUCTION IN RISK OF DEATH OVER 5 YEARS
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Treatment for Morbid Obesity
• Surgery is only a TOOL
• A TOTAL PROGRAM facilitates success– Pre-Surgical & Post-Surgical counseling– Nutritional counseling– Exercise & Weight Management Programs– Psychological evaluations & counseling– Support groups– Patient for Life
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Multidisciplinary Team Approach
Bariatric Surgeons Physician / Bariatrician Case Manager Nurse Specialist Registered Dietitians Exercise Physiologist/ Physical
Therapist Behavioral Psychologist Research coordinator and technician Insurance Coordinator
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Overview of Bariatric Surgery Process
• Stop smoking 60 days prior to surgery• 10% weight loss from initial presentation• Read book & complete 10 behavior
modification modules• Attend 2 educational groups sessions• Attend 2 patient support groups• Metabolism / body composition
determination• Psychiatric evaluation• Medical evaluation• Surgical evaluation
(at least 6 months)
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Who Is a Surgical Candidate?
• Meets current criteria• Failed medically supervised weight loss
attempts• Age limits vary by program• No endocrine cause of obesity• Acceptable operative risk• Understands surgery & risks • Absence of active drug or alcohol issues • No uncontrolled psychological conditions• Consensus by multi-disciplinary team• Dedicated to life-style change & follow-up
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Indications for Bariatric Surgery
CMS (2006)
– BMI > 35 w/co-morbid condition– Documented ineffective weight loss
attempts– Center of Excellence– Specific procedures: RNY (open & lap),
LAGB®, BPD, BPD/DS; excludes VBG– Surgery- for treatment of co-morbidities and
medical complications related to obesity
Decision Memo for Bariatric Surgery for the Treatment of MO (CAG0025OR)
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Centers of Excellence
Resources to perform safe bariatric surgery
• Equipment, Supplies & Training of Surgeons• Multi-Disciplinary Team
Excellent short & long term outcomes• Objective Data Outcome• Clinical Pathway & Process
http://surgicalreview.org/
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Post Operative Bariatric Care:Routine Follow up Visits
• Match appointment w. surgeon, internist & RD• Adjust medications & vitamins• Advance Diet• Access fluid & protein intake• Physical function testing • Complete QOL, BDI, Mood surveys• Repeat metabolism / body comp determination• Follow up biometrics as indicated
(1 week; 1 month; 2 months; every 6 months; every year)
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Communication between Program -
PCP, Health Plan & Employer
is Imperativefor Long-term Success
Plan for SurgeryPlan for Postoperative CarePlan for Long-term follow up
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Improvement of Co-Morbid Conditions
•86% of diabetes resolved or improved•70% of hyperlipidemia improved•78.5% of hypertension resolved improved•83.6% of sleep apnea resolved or
improved•400% Reduced incidence of cancer
(2.03% vs. 8.49%)
Buchwald H, Avidor Y, Braunwald E, et al. Bariatric Surgery – A Systematic Review of the Literature and Meta-analysis. Journal of the American Medical Association, October 13, 2004 – Vol. 292, No. 14
136 studies representing all together 22,094 patients
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Reduction in Medication Costs…
0
50
100
150
200
250
Total DM HTN
Pre
scri
pti
on
Med
icat
ion
Co
st
Pre-RYGBP Post-RGBP
Monthly Prescription Medication Costs before and after RYGBP
Potteiger CE, et al. Obesity Surgery, 2004:14:725-730
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Weight Loss Surgery Results in:
• 89% Decreased Risk of Death(including 0.4% operative mortality)
• 67% long-term loss of excess body weight
• 45% Reduction in total health care costs (including cost of surgical procedure)
• 50% Reduced hospital days
Christou (McGill University, Montreal, Canada)
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0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
Gall Bladder Gastric Bypass Heart Surgery
Mortality (in Percentage)
Mortality Rates in Context
1. Bariatric Mortality - Buchwald H, Avidor Y, Braunwald E, et al. Bariatric Surgery – A Systematic Review of the Literature and Meta-analysis. Journal of the American Medical Association, October 13, 2004 – Vol. 292, No. 14.
CABG Mortality – Angelin, Lancet 2002.
Cholecystectomy Mortality – Muller BP, Holzinger F, Leeping H, Klaiber C. Laparoscopic Cholecystectomy: Quality of Care and Benchmarking. Surgical Endoscopy 2003, Vol. 17, No. 2, pp. 300-305.
2.0%
.5%.2%
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19961991
Obesity Trends* Among U.S. AdultsBRFSS, 1991, 1996, 2004
(*BMI 30, or about 30 lbs overweight for 5’4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
2004
Behavioral Risk Factor Surveillance System, CDC. F as in Fat: How Obesity Polices are Failing in America: 2005
Ranks 22nd
23% obese6% diabetic
Ranks last16.8% obese4.3% diabetic
Ranks #129.5% obese9.6% diabetic
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Conclusion
The magnitude of the problem (obesity) is great
A comprehensive approach (diet, exercise, behavior modification) is the best approach for success
Continuum of Care (wellness, weight management & bariatric surgery) will insure a healthier population
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Conclusion
Surgically induced weight-loss in Morbid Obesity
Decreases mortality risk
Decreases the risk of developing new health-related conditions
Reduces health care utilization and direct health care costs
Co-morbidities are resolved, alleviating additional treatment & pharmaceutical costs
The Impact of Weight Reduction Surgery on Health-Care Costs in Morbidly Obese Patients; Obesity Surgery, 14, 939-947; John S. Sampalis, PhD; Moiseh Liberman,MD, Stephane Auger, BSc, Nicolas V.
Christou, MD PhD
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ConclusionSuccessful Treatment of the MO
patientcollaborative effort
Bariatric Team (Surgeon, Bariatrician, RD, Mental Health Counselor)
Primary Care PhysicianHealth Plan (case manager)Employer
All disciplines must work together to ensure an optimal outcome with long-term results
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Resources
Websites:
– http://www.geisinger.org/consumers/services/gastro_nutr/
– http://www.asbs.org/– http://www.weightlosssurgeryinfo.com
/– http://www.fitday.com/– http://www2.epocrates.com/index.htm
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