The Impact of Obesity and its Treatment Options

Bayhealth Bariatric ProgramRahul Singh, MD

Patty Deer, RN, BSN, CNOR

Crystal Bouchard, RD, LDN

What are you going to learn today?

• What is Obesity?

• The Consequences of Untreated Obesity

• Obesity Risk Factors

• Obesity Treatment Options

• Bayhealth Bariatric Program/Patient Selection

• Components of Structured Surgical Weight Loss Program

What is Obesity?

• Multifactorial disease of excess fat storage with a genetic basis

• Associated with multiple serious medical problems

• Influenced by the environment

• Lifelong and progressive

• Potentially life limiting

What is Morbid Obesity?

Considered to be clinically severe. Morbid obesity is defined as:

– >200% of ideal weight or >100 lb overweight

– Body Mass Index (BMI) of 40

– BMI 35 with one or more associated diseases

NHLBI 2000 (NIH), Practical Guide: Identification, Evaluation and Treatment of Overweight and Obesity in Adults

What Does Obesity Look Like

or How Do We Measure Obesity?

Normal Weight (BMI 19 to 24.9)

130#BMI 22

Normal Weight (BMI 19 to 24.9)

130#BMI 22

Overweight(BMI 25 to 29.9)

152#BMI 26

Overweight(BMI 25 to 29.9)

152#BMI 26

Obese (Class I)(BMI 30 to 34.9)

175#BMI 30

Obese (Class I)(BMI 30 to 34.9)

175#BMI 30

Obese (Class II)(BMI 35 to 39.9 )

205#BMI 35

Obese (Class II)(BMI 35 to 39.9 )

205#BMI 35

Morbidly Obese(BMI 40 or more)

234#BMI 40

Morbidly Obese(BMI 40 or more)

234#BMI 40

Agency for Healthcare Research and Quality. Screening for obesity in adults. Accessed June 22, 2010 from http://www.ahrq.gov/clinic/3rduspstf/obesity/obeswh.htmDugdale DC. Obesity. MedlinePlus. Accessed June 22, 2010 from http://www.nlm.nih.gov/medlineplus/ency/article/007297.htm

Based on 5’4” F

emale

Morbid Obesity Trend: An “Epidemic within an Epidemic”

Trust for America's Health and the Robert Wood Johnson Foundation report "F as in Fat: How Obesity Threatens America's Future 2012."

Obesity Trends In America

•Currently 35.7 percent of American adults and 16.9 percent of children ages 2 to 19 are obese (defined as a body mass index over 30).

•If trends do not change, by 2030 the obesity rate for adults could top 44 percent nationally. In addition, rates could exceed 50 percent in 39 states and 60 percent in 13 states.

•More than 25 million Americans have type 2 diabetes, 27 million have chronic heart disease, 68 million have hypertension and 795,000 suffer a stroke each year. Approximately one in three deaths from cancer each year (approximately 190,650) are related to obesity, poor nutrition or physical inactivity.

Obesity Trends In America… Continued

•In the next 20 years, obesity could contribute to more than 6 million cases of type 2 diabetes, 5 million cases of coronary heart disease and stroke, and more than 400,000 cases of cancer.

•By 2030 costs associated with treating preventable obesity-related diseases are estimated to increase by $48 billion to $66 billion a year. The loss in economic productivity could be between $390 and $580 billion annually.

•It's also projected that if the average body mass index was reduced by just 5 percent by 2030, thousands or millions of people could avoid obesity-related diseases, thereby saving billions of dollars in health care costs.

Trust for America's Health and the Robert Wood Johnson Foundation report "F as in Fat: How Obesity Threatens America's Future 2012."

Prevalence of Significant Morbidities per Weight

Mokdad AH, Ford ES, Bowman BA, et al. Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. JAMA 2003;289:76."* Increase in mortality rate from cancers of all kinds compared to lowest risk group (BMI 25-30). From Calle EE, Rodriguez C, Walker-Thurmond K,et al. Overweight, obesity and mortality from cancer in a prospectively studies cohort of US adults. New Engl J Med 2003;348:1625."

Consequences of Untreated Obesity =

Co morbidities

•Type-2 Diabetes1,3•Hypertension1,3•Hyperlipidemia1,3•Respiratory disease1,3 •Sleep apnea1,2,3•Depression3•Menstrual irregularity2

•Amenorrhea2•Dysmenorrhea2

•Urinary stress incontinence3•Asthma/pulmonary disorder2,3•Cancer1,3

•Gastroesophageal reflux disease (GERD)2,3•Degenerative joint disease (DJD)3•Heart disease 2 •Gallstones1,2,3•Fatty liver disease2,3•Coronary artery disease1,3 •Stroke1•Osteoarthritis1,2•Infertility2•Metabolic Syndrome

1. NHLBI 2000 (NIH), Practical Guide: Identification, Evaluation and Treatment of Overweight and Obesity in Adults

2. NIDDK 2006 (NIH), Understanding Adult Obesity.3. Schneider BE & Mun EC. Diabetes Care. 2005; 28:475-80

Co Morbidities: Metabolic Syndrome

Hyper-Insulinemia

Dyslipidemia Hypertension

Heart Disease

Central Morbid Obesity

Insulin Resistance

Type 2 Diabetes

Complex interaction between genetic, metabolic, and environmental factors

Recent studies suggest metabolic syndrome may be an

inflammatory state.

Adapted from Lee YH, Pratley RE. The evolving role of inflammation in obesity and the metabolic syndrome. Curr Diab Rep. 2005;5:70-75.

Diabetes

•ADA Position statement on diabetes care1:–Bariatric surgery should be considered for adults with BMI ≥ 35 kg/m2 and type 2 diabetes, especially if the diabetes is difficult to control with lifestyle and pharmacologic therapy.

–Patients with type 2 diabetes who have undergone bariatric surgery need life-long support and medical monitoring.

1. American Diabetes Association. Standards of medical care for diabetes – 2009. Diabetes Care. 32(S1); S13-S44. January 2009.

Cardiovascular Disease• Hypertension is 6 times more frequent in obese subjects

than in lean men and women.1

• A 10 kg higher body weight is associated with a 3 mm Hg higher systolic and a 2.3 mm Hg higher diastolic blood pressure.1

• These increases translate into an estimated 12% increased risk for coronary heart disease.1

• It’s estimated that the risk of congestive heart failure increases 5% for men and 7% for women for each 1 unit increase of BMI.2

1Poirier P, Giles TD, Bray GA, et al. “Obesity and Cardiovascular Disease: Pathophysiology, Evaluation, and Effect of Weight Loss: An Update of the 1997 American Heart Association Scientific Statement on Obesity and Heart Disease From the Obesity Committee of the Council on Nutrition, Physical Activity, and Metabolism.” Circulation. 2006;113:898-918."2Kenchaiah S, Evans JC, Levy D, et al. Obesity and the risk of heart failure. NEJM 2002; 347:305-313. "

Obstructive Sleep Apnea

•Obesity is the most powerful risk factor for obstructive sleep apnea (OSA)

•Potentially modifiable risk factors for OSA also include alcohol, smoking, nasal congestion, and estrogen depletion in menopause.

•Data suggest that obstructive sleep apnea is associated with all these factors, but at present the only intervention strategy supported with adequate evidence is weight loss. (Young et al. 2002)

•About 70% of those with OSA are obese (Malhotra et al 2002)

•Total body weight, BMI, and fat distribution all correlate with odds of having OSA - Every 10 kg increase in weight increases risk by 2X - Every increase in BMI by 6 increases risk by 4X - Every increase in waist or hip circumference by 13 to 15 cm increases risk by 4X (Young et al 1993)

Impact of BMI on LongevityImpact of Obesity on Mortality and Years of Life Lost

Graph represents years of life lost for white men.Fontaine KR, Redden DT, et al. Years of life lost due to obesity. JAMA 2003;289:187.

Traditional Weight Loss

Therapies

Comparison of Atkins®, Ornish, Weight Watchers®, and Zone Diets •Randomized trial of 160 patients with average BMI of 35 (enrollment 2000 to 2002)

•Medically supervised

•Each diet reduced the LDL/HDL ratio by 10 percent

Dansinger ML, Gleason JI, Griffith JL, et al. Comparison of the Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart disease reduction. JAMA 2005;293(1)43-53.Atkins is a registered trademark of Atkins Nutritionals, Inc.Weight Watchers is a registered trademark of Weight Watchers International, Inc.

Type of Diet Completing One YearWeight Loss at One

Year

Atkins® 21/40 (53%) 2.1 kg (4 lbs.)

Zone 26/40 (65%) 3.2 kg (7 lbs.)

Weight Watchers® 26/40 (65%) 3.0 kg (6 lbs.)

Ornish 20/40 (50%) 3.3 kg (7 lbs.)

Program Name | Date

Weight Loss of Various Treatments for Morbid Obesity

* Average Weight Loss from baseline; meta-analysis of various studies up to 4 years in length.

1Bray GA. Lifestyle and pharmacologic approaches to weight loss: Efficacy and safety. J Clin Endocrinol Metab, 2008; 93(11): 581-588.2Buchwald H, Avidor Y, Braunwald E et al. Bariatric surgery: A review and meta-analysis. JAMA 2004; 292(14):1724-1737. Meta-analysis of studies with at least 30 days of follow-up, with the majority of followup at two years or less.3Brethauer SA, Hammel JP, Schauer PR. Systematic review of sleeve gastrectomy as staging and primary bariatric procedure. Surg Obes Relat Dis. 2009;5:469-475. Meta-analysis of studies from 3 to 60 months followup.

TreatmentExcess

Weight Loss

Lifestyle / Pharmacologic Treatments1

(Diets, lifestyle programs, sibutramine, orlistat, rimonabant)

<10%*

Laparoscopic Adjustable Gastric Banding2 48%

Sleeve Gastrectomy3 55%

Gastric Bypass Surgery2 62%

Surgical Weight Loss Procedures

Restrictive• Laparoscopic Adjustable Gastric Banding• Sleeve Gastrectomy

Combination/Restrictive & Malabsorptive• Roux-en-Y Gastric Bypass• Duodenal Switch / Biliopancreatic Diversion

Restrictive

Dissect approximately three-fourths of

the stomach

Malabsorptive & Restrictive

Bypass a portion of the small intestine and create a

15-30cc stomach pouch

Vertical Sleeve Gastrectomy

Current Most-Used Bariatric Techniques

Adjustable Gastric Banding

Roux-en-Y Gastric Bypass

Restrictive

Place implantable device around upper most part of stomach

Adjustable Gastric Banding• Laparoscopic• Least invasive• Restrictive• Mean excess weight

loss of 48%2

• Requires implanted medical device

• Ongoing maintenance required– Adjustments/Fills

2. Buchwald, H, Avidor Y, Braunwald E, et al. Bariatric surgery: A systematic review and meta-analysis. JAMA.

2004; 292:1724-37.

Potential Risks and Complications of Gastric Banding

• Anorexia• Band erosion / slippage• Band leak / malfunction• Esophageal spasm • Gastroesophageal reflux

disease (GERD) • Gastric perforation• Inflammation of the esophagus

or stomach • Migration of implant (band

erosion, band slippage, port displacement)

• Outlet obstruction

• Pouch dilation • Port-site hernia or infection • Reservoir leakage / twisting• Tubing-related complications

(port disconnection, tubing kinking)

Vertical Sleeve Gastrectomy

• Laparoscopic• Restrictive• Mean excess weight

loss of 55%2

• No implanted medical device

2. Brethauer SA, Hammel JP, Schauer PR. Systematic review of sleeve gastrectomy as staging and primary bariatric Procedure. Surg Obes Relat Dis. 2009;5:469-‐475.

Risks and Complications of Vertical Sleeve Gastrectomy

• Abdominal hernia • Chest pain • Collapsed lung • Constipation or diarrhea • Dehydration • Dyspepsia• Enlarged heart • Esophageal dysmotility• Fistula• Gallstones, biliary colic,

cholecystitis

• Gastric leakage• Gastrointestinal

inflammation or swelling

• Staple line leak• Stoma obstruction • Stomach dilation• Surgical procedure

repeated• Ulcers• Vomiting and nausea

Roux-en-Y Gastric Bypass• Can be laparoscopic• Restrictive/Malabsorptive• Most frequently

performed bariatric procedure

• Mean excess weight loss at 1 year of 62%1

• No implanted medical device

1. Buchwald, H, Avidor Y, Braunwald E, et al. Bariatric surgery: A systematic review and meta-analysis. JAMA. 2004; 292:1724-37

Potential Risks and Complications of Roux-en-Y Gastric Bypass

• Anastomotic/staple line leak • Bowel obstruction• Cholecystitis• Chronic anemia• Diagnostic challenges due to

potential difficulty in detecting the stomach, duodenum, or parts of the small intestine

• Dumping syndrome• Fistula• Gastric pouch dilation

• Internal hernia• Intestinal irritation• Marginal ulcers • Nutritional deficiencies • Osteoporosis• Pancreatitis• Stricture• Vitamin deficiency

Advantages of Laparoscopic Roux-en-Y Gastric Bypass

• Highest weight loss at 5 years

• Highest rate of resolution of other medical conditions 1

• Diabetes >80%

• High Blood Pressure >65%

• Seep Apnea 75%

• High Cholesterol 65%

1. Tice, J ; AJM:2008 Vol 121, No 10, Gastric Banding or Bypass ? A systematic review

Mean Excess Weight Loss 1 Year

• LAGB 48%

• Sleeve Gastrectomy 55%

• RYGB 62%

Bariatric Surgery Has a Low Incidence of Mortality

1Mortality rate when performed at a Bariatric Surgery Center of Excellence; Bariatric Surgery: DeMaria EJ, Pate V, Warthen M et al. Baseline data from American Society for Metabolic and Bariatric Surgery-designated Bariatric Surgery Centers of Excellence using the Bariatric Outcomes Longitudinal Database, Surgery for Obesity and Related Diseases. Article in Press.2Dolan JP, Diggs BS, Sheppard BC et al. The National Mortality Burden and Significant Factors Associated with Open and Laparoscopic Cholecystectomy: 1997–2006. J Gastrointest Surg. 2009; 13:2292-23013Lie SA, Engesaeter LB, Havelin LI et al. Early postoperative mortality after 67,548 total hip replacements. Acta Orthopaedica 2002; 73(4):392-399 4Ricciardi R; Virnig BA, Ogilvie Jr. JW. Volume-Outcome Relationship for Coronary Artery Bypass Grafting in an Era of Decreasing Volume. Arch Surg. 2008;143[4]:338-344

BARIATRIC SURGERYLosing 50% to 70% of excess weight1 may be just the beginning…

Surgical Therapy for Morbid Obesity

Bariatric Surgical Candidate• BMI >35 with co-morbidities or >40 without• Healthy enough to undergo a major operation• Failed attempts at medical weight loss• Absence of drug and alcohol problems • No uncontrolled psychological conditions• Consensus by multi-disciplinary team• Understands surgery and risks

Must be dedicated to a lifestyle change and lifetime follow-ups

Determining the appropriate procedure for each patient

Considerations– Age– Health Risk (depending on co morbidities)– Amount of weight to lose– Lifestyle– Eating behaviors

Mutual decision between patient and surgeon– Discuss with surgeon during initial consultation– Discuss with family and friends

The Bariatric Program at Bayhealth

Surgeons: -- Rahul Singh, M.D.

-- Thomas Barnett, M.D.

-- Assar Rather, M. D.

Bariatric Program Personnel

• Patty Deer, RN, BSN, CNOR – Bariatric Program Coordinator

• Crystal Bouchard, RD, LDN - Dietitian

• Donna Hartzell, LPN - Office Coordinator

Bariatric Program Patient Selection Criteria

• Patients can be referred to the Bariatric Surgical Weight Loss Program by self referral or physician referral.

• Informational Seminars are offered monthly • The patient must have Body Mass Index greater than or equal to 40.

Patients with a BMI between 35 and 40 will be considered when there is documentation of a co-morbid condition such as hypertension refractory to standard drug regimens, cardiovascular disease, degenerative joint disease, documented obstructive sleep apnea, and diabetes

• The patient must have been with the condition of morbid obesity for at least 5 years. Patients must have failed weight loss programs within the past 2 years.

Program Process Cont. • All patients will be evaluated preoperatively by a licensed mental

health provider. To ensure that patient’s ability to understand, tolerate, and comply with all phases of care and to ensure the patient’s ability to commit to a long-term life style change. The evaluation will ensure that any psychiatric, chemical dependence or eating disorder contraindications to the surgery will be ruled out. Documentation of this evaluation will be completed prior to any scheduling of surgery.

• Nutrition Education and weight loss typically no less than 6 months

• Scheduled appointments with Bariatric Program Coordinator

(Initial/Clearance Assessment/Pre-op/Post-op)

Bariatric Program Process • Informational Seminar Attendance (Mandatory)

• Verify benefits and obtain insurance authorization

• Initial consultation with Program Coordinator and Surgeon

• Nutritional evaluation & counseling with our dieticians

• Psychological evaluation

• Sleep Study and Pulmonary Clearance

• Cardiology Clearance

• Primary Care Clearance

• Support Group attendance

• Pre-operative testing (Labs, EGD, UGI)

• Surgery

• Lifelong follow-up appointments and support groups

Surgery Is The Beginning

• Shift focus from surgical procedure to Lifelong Lifestyle changes!

• Behavior Modification• Eating and dietary guidelines• Positive reinforcement and support• Multidisciplinary team consensus• Support Groups/Follow up visits• Motivation comes from weight loss & co morbidity

resolution

Nutrition Component

• Seminar>Coordinator>Initial consultation

• Most insurances require 6 month of dietitian monitored nutrition counseling.

• Months must be consecutive

• Must show constant steady improvement

Nutrition Component cont.

• Pt must follow a strict dietary lifestyle before and after surgery

• 1:1, or classes

• Food and nutrient education specific to procedure

Nutrition Component cont.

• Meal Plans• Food journals• Protein tracking• Monthly weight in• Physical activity tracking• Goal setting• Supplement reinforcement• Post op habits reinforced

Nutrition Component cont.

• 4 week follow up

• Close follow up care/nutrition classes

References1. Young T, Peppard PE, Gottlieb DJ. Epidemiology of obstructive sleep apnea: a population health perspective. Am Jnl of Resp and

Crit Care Med 165 (2002) 1217-1239.2. Malhotra A, White DP. Obstructive sleep apnea. Lancet 2002;360(9328)237-45.3. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged

adults. N Engl J Med 1993;328(17)1230-54. 1Bray GA. Lifestyle and pharmacologic approaches to weight loss: Efficacy and safety. J Clin Endocrinol Metab, 2008; 93(11): 581-

588.5. 2Buchwald H, Avidor Y, Braunwald E et al. Bariatric surgery: A review and meta-analysis. JAMA 2004; 292(14):1724-1737. Meta-

analysis of studies with at least 30 days of follow-up, with the majority of followup at two years or less.6. 3Brethauer SA, Hammel JP, Schauer PR. Systematic review of sleeve gastrectomy as staging and primary bariatric procedure. Surg

Obes Relat Dis. 2009;5:469-475. Meta-analysis of studies from 3 to 60 months followup.7. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: A systematic review and meta-analysis. JAMA 2004; 292(14):1427-378. Schauer PR, Ikramuddin S, Gourash W, et al. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg

2000; 232(4): 515-299. DeMaria EJ, Sugerman HJ, Kellum JM, et al. Results of 281 consecutive total laparoscopic Roux-en-Y gastric bypasses to treat

morbid obesity. Ann Surg 2002; 235(5): 640-5; discussion 645-7.10. Sugerman HJ, Sugerman EL, Wolfe L, et al. Risks and benefits of gastric bypass in morbidly obese patients with severe venous

stasis disease. Ann Surg 2001; 234(1): 41-6.11. Wittgrove AC, Clark GW. Laparoscopic gastric bypass, Roux-en-Y – 500 patients; technique and results, with 3-60 month follow-up.

Obes Surg 2000; 10(3): 233-9.12. Mattar SG, Velcu LM, Rabinovitz M, et al. Surgically-induced weight loss significantly improves nonalcoholic fatty liver disease and

the metabolic syndrome. Ann Surg 2005; 242(4): 610-2013. Christou NV, Sampalis JS, Liberman M, et al. Surgery decreases long-term mortality, morbidity, and health care use in morbidly

obese patients. Ann Surg 2004; 240(3):416-23; discussion 423-4.14. Surgerman HJ, Felton WL, 3rd, Sismanis A, et al. Gastric surgery for pseudotumor cerebri associated with severe obesity. Ann Surg

1999; 229(5): 634-40; discussion 640-2.15. Schauer PR, Brugera B, Ikramuddin S, et al. Effect of laparoscopic Roux-en-Y gastric bypass on type 2 diabetes mellitus. Ann Surg

2003; 238(4): 467-84; discussion 84-5.16. Eid GM, Cottam DR, Velcu LM. Effective treatment of polycystic ovarian syhdrome with Roux-en-Y gastric bypass. Surgery for

Obesity and Related Diseases 2005; 1:77-80.