Advances in the Understanding

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Advances in the Understanding Treatment of
Morbid Obesity

• Christopher Still, DO, FACN, FACP
• Director, Center for Nutrition Weight
  Management
• Geisinger Health Care System

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Who Am I??

• Internist
• Master of Science in Clinical Nutrition
• Residency Internal Medicine
• Fellowship Obesity Medicine Nutrition
  Support
• Board certified
• American Board of Internal Medicine
• American Board of Nutrition
• American College of Nutrition
• National Board of Nutrition Support

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Why all the Interest in Obesity Treatment?

• Discovery of obesity genes
• Management Medical / Surgery
• Epidemic

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More Than One Half of US Adults Are Overweight or
Obese
Overweight or Obese US Adults
BMI ? 30
BMI 25 - 29.9
63
55.0
43.3
46.1
46.0
NHLBI. Obes Res. 19986(suppl 2)51S-209S. Flegal,
et al. Int J Obes. 19982239-47.
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Disproportional Increase in Severe ObesityMore
than 1,000,000 U.S. adults now have a BMI 50
6

• Appetite
• Mood
• Stress

• Food
• Availability
• Composition

• Exercise
• Time
• Compliance

• Metabolism
• Genetics
• Medications

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Energy Savers
personal computers tele-commuting cellular
phones e-mail/Internet shopping by phone
food delivery services phone extensions
dishwashers escalators/elevators cable
movies drive-thru windows computer
games intercoms moving sidewalks remote
controls garage door openers
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• Appetite
• Mood
• Stress

• Food
• Availability
• Composition

• Exercise
• Time
• Compliance

• Metabolism
• Genetics
• Medications

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Definition of Obesity
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Body Mass Index (BMI)

• Defined as weight (kg)/ height (m)2
• Evaluates weight relative to height
• Replaces the percentage of ideal body weight
• Correlates highly with body fat and with
  morbidity and mortality

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Definition of Morbid Obesity

• Greater than 100 lbs. overweight, or body mass
  index (BMI) of ?40
• Stedmans definition sufficient to prevent
  normal activity or physiologic function or to
  cause the onset of a pathologic condition

www.asbs.org
Trust for Americas Health Facts
2004 http//www.cdc.gov/pcd/issues/2005/jan/04_008
7.htm
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Obesity and Mortality Risk, 1989
1 Adapted with permission from Gray DS. MedClin
North Am. 1989731
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Obesity Facts

• 30 or 130 million of U.S. adults are obese
• Prevalence of obesity continues to rise. From
  1960 to 2002, prevalence of obesity among adults
  age 20-74 more than doubled from 13.3 to 30.5
• Attributable to co-morbidities such as
  hypertension, heart disease, stroke and diabetes
• Increases risk of cancer

Obesity is the most common preventable cause
of death second to smoking
Sources National Center for Health Statistics,
2002 http//win.niddk.nih.gov/statistics/index.ht
mecon
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Obesity Facts (cont)

• 15 million obese adults with BMI 35
• 7th leading health problem in the U.S. workforce

6th leading cause of lost productivity
Sources NIH, 2000 Integrated Benefits Institute
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Costs of Obesity

• 123 billion/year
• Direct costs 64.1 billion
• Indirect costs 58.8 billion
• 33 billion on weight loss products and services

9.1 of total annual medical care expenditure are
related to obesity
Sources http//win.niddk.nih.gov/statistics/index
.htmecon Lipincott, et al. Obesity Mechanisms
and Clinical Management. 2002.
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Employer Cost Measures

• 1. Indirect Costs
• Absenteeism
• Presenteeism lowered productivity while at
  work
• Restricted Activities
• 2. Direct Costs
• Health Insurance

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Employer Costs (cont)

• Indirect Cost (Lost Productivity in Age 17-64
  workforce) 3.9 billion/year
• 239 million restricted activity days/year
• 39.3 million work days lost/year
• Direct Costs 10 billion/year
• At least 8 of private employer medical claims
  are attributed to health claims related to obesity

Total Cost to U.S. Employers due to Obesity 14
billion/year
Sources The U.S. Department of Health and Human
Services, 1994 Finkelstein et al. National
medical spending attributable to overweight and
obesity How much, and whos paying? Health
Affairs, May 14, 2003
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Obesity Greater Rates of Disability
12.6
Percent Unable to Work
9.6
7.9
5.9
5.6
4.7
Healthy Weight
Overweight
Obese
Men
Women
Thompson, D.et al. Am J Health Promot
199812120-127
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Medical Co-Morbidities
Depression
Stroke
Diabetes
Abnormal PFTs
GERD
Gall bladder disease
Steatosis
Breast, uterus, cervix
Osteoarthritis
PCOS
Phlebitis
PCOS polycystic ovarian syndrome
Premature Death
Gout
NASH nonalcoholic steatohepatitis
NIH/NHLBI. September 1998 NIH publication no. 98
4083.
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So How Do We Treat Obesity?
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Components of an Effective Obesity Management
Program
Wadden TA, Foster GD. Behavioral treatment of
obesity. Med Clin North Am. 200084441-461 Stumbo
, PH, et. al. Dietary and medical therapy of
obesity. Surg Clin N Am 85(2005)703-723
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Medical ManagementTreatment Plan

• 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

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Diet and Physical Activity
0- 2- 4- 6- 8- 10- 12- 14- 16-
Weight loss/gain (kg)
1 2 3 4 5 6 7 8 9 10 11
12 30
Treatment (wk)
Follow-up (mo)
Exercise
Nonexercise
Pavlou KN, et al. Am J Clin Nutr. 198949115-1123
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Presently Approved Weight Loss Medications
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Weight Loss Medications
1Knoll Pharmaceutical Company. 2 Roche Group. 3
Phentermine (generic)
Epocrates Rx Online. San Mateo (CA) Epocrates,
Inc. 2003-(cited 2006 Jan 23). http//www2.epocrat
es.com Zhaoping Li, MD, PhD, et. al.
Meta-analysis Pharmacologic Treatment of
Obesity. Ann Intern Med. 2005142532-546.
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Medical Treatment Results

• Degree of weight loss
• Recidivism
• Unrealistic expectations

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Success Rate of Various Weight Loss Treatments

• Conventional (obese)
• Diet
• Exercise
• Behavior Modification
• Anti-Obesity Drugs

• 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

http//www.nhlbi.nih.gov/guidelines/obesity/practg
de.htm accessed 5 February 2006
Rosenbaum M, Leibel RL. Obesity
Medical Progress. NEJM 1997 337396-407.
Buchwald, H
et. al. Bariatric Surgery A Systematic Review and
Meta-analysis. JAMA 2004 2921724-1737
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Modest Weight Loss among Diabetics Decreases
Diabetes Medication
43.2
28.9
11.7
6.2
4.3
0
Hollander PA. Diabetes Care 1998211288-94.
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Expected Disease-Years Averted with 10 Weight
Loss
Selected Diseases CHD, type 2 DM, hypertension,
hypercholesterolemia, stroke
Adapted from Oster G, et al. Am J Public Health
1999891536-1542.
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Expected Cases Averted with 10 Weight Loss
Selected Diseases CHD, type 2 DM, hypertension,
hypercholesterolemia, stroke
Adapted from Oster G, et al. Am J Public Health
1999891536-1542.
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Bariatric Surgery
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Bariatric (Weight-Loss) Surgery
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Treatment for Morbid Obesity

• Surgery is only a TOOL
• NOT a cure

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Multidisciplinary Team Approach

• Bariatric Surgeons
• Physician / Obesity Medicine Specialist
• Case Manager
• Nurse Specialist
• Registered Dietitians
• Exercise Physiologist/ Physical Therapist
• Behavioral Psychologist
• Research coordinator and technician
• Insurance Coordinator

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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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Why Consider Surgery ?

• Men with a BMI 40, ages 25-34, have a 12-fold
  increase in overall mortality
• Plus the morbidity of the obesity related medical
  problems
• Decrease in quality of life
• Management of obesity related co-morbities
  (DM,OSA, HTN, CHF,DJD)

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Surgical Intervention
Adjustable Gastric Band (Lap-Band)
Roux-en-Y Gastric Bypass
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Why Consider Bariatric Surgery ?

• NOT a cosmetic procedure
• Cure or improve obesity related co-morbidities

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BUCHWALD et al. JAMA, Oct. 2004

• Study Goals assess impact of bariatric surgery
  on
• Diabetes
• Obstructive sleep apnea
• Hypertension
• Hyperlipidemia

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STUDY DESIGN

• Meta-analysis of publications with comorbidity
  resolution endpoints since 1990
• 136 studies fit strict criteria and were
  extracted and meta-analyzed for the 4 comorbidity
  endpoints
• These studies include data on over 22,000
  patients
• Outcomes were analyzed separately for each
  bariatric surgery type to account for
  inter-procedure variability
• Also extracted weight loss and 30-day mortality

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Bariatric SurgeryA Systematic Review and
Meta-analysis

• Excess Weight Loss
• All Patients 61.2 (58.1-64.4)
• Gastric Banding 47.5 (40.7-54.2)
• Gastric bypass 61.6 (56.7-66.5)
• Gastroplasty 68.2 (61.5-74.8)
• BPD/DS 70.1 (66.3-73.9)
• Operative mortality ( 30 days)
• Restrictive procedures 0.1
• Gastric bypass 0.5
• BPD/DS 1.1
• Comorbidity Resolution
• Diabetes 76.8
• Hyperlipidemia 70.0 (improved not
  resolved)
• Hypertension 61.7
• Obstructive sleep apnea 85.7

Buchwald et al. JAMA. 20042921724-1737
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Surgical Cost Benefit Analysis Studies

• Van Gemert, et al. Prospective analysis including
  co-morbid conditions. Obesity Surgery, 1999.
• Surgical treatment saved 4,000/QALY
• Increased number of patients engaging in
  paid labor from 19 before surgery to 48 after
  surgery
• Increased productivity gain of 2,765/year
• 2. Gallagher, et al. The Impact of Bariatric
  Surgery on the Veterans
• Administration (VA) Healthcare System A Cost
  Analysis. Obesity Surgery. 2003.
• Healthcare costs are reduced after bariatric
  surgery due to decreased routine outpatient
  visits
• Outpatient visits reduced from 55 to 18
  postoperatively.
• The cost/yr of all care after surgery was
  2,840/patient vs. 10,800 preop

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Surgical Cost Benefit Analyses Studies (contd)

• 3. Narbro, Sick Leave Disability Pension
  Analyses.
• Operated patients resulted in fewer days of
  sick leave and disability pension after 1 year
  postoperatively
• Results more prominent among workers age 47,
  with14-18 fewer days of sickness
• 4. Monk Jr., et al. Pharmaceutical Savings after
  Gastric Bypass Surgery. Obesity Surgery. March,
  2004.
• -- RYGBP leads to savings in average
  medication expenses per person for co-morbidities
  from 317/month preoperatively ? 135/month
  postoperatively or 2,184/year savings per person
• -- Medication savings were highest for GERD
  81.73 ? 33.87 and asthma 52.4519.66

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CHRISTOU et al. ANNALS OF SURGERY, AUG. 2004

• Study Goal assess impact of bariatric surgery
  on
• Morbidity
• Mortality
• Healthcare utilization and healthcare costs

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Implication of not managing morbid obesity
89 REDUCTION IN RISK OF DEATH OVER 5 YEARS
Includes peri-operative (30-day) mortality of
0.4 p-value 0.001 Christou (McGill University,
Montreal, Canada)
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FIVE YEAR HEALTHCARE UTILIZATION
REDUCTION IN HEALTHCARE UTILIZATION
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AVERAGE CUMULATIVE COSTS PER 1,000 PATIENTS FOR
HOSPITALIZATIONS BY GROUP YEAR OF FOLLOW-UP
HOSPITALIZATION COST REDUCTION
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Comparative Mortality

• Craniotomy ? 10.7
• Esophagectomy ? 9.1
• Pancreatectomy ? 8.3
• Pediatric Heart ? 5.4
• Aortic Aneurysm ? 3.9
• CABG ? 3.5
• Hip Replacement ? 0.3

Bariatric Surgery ? 0.28
Adopted from Dimiek et al. JAMA 2004292847-851
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Realistic Expectations
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Prevalence of Obesity, 1991
1015 obese
No data
15 obese
Mokdad AH, et al. JAMA. 199928215191522.
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Prevalence of Obesity, 1998
1015 obese
15 obese
Mokdad AH, et al. JAMA. 199928215191522.
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Conclusions

• Obesity is a chronic, debilitating disease that
  has devastating medical and economical
  consequences
• Although medical management can produce modest
  weight loss with medical and economic benefits,
  there remains a high rate of recidivism
• Bariatric surgery for morbidly obese patients
  results in more profound and long term weight and
  co-morbidity improvements
• To ensure the most optimal outcomes, obesity
  treatment should include a multidisciplinary
  program if possible

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