The Impact of Obesity and its Treatment Options

1
The Impact of Obesity and its Treatment Options

• Bayhealth Bariatric Program
• Rahul Singh, MD
• Patty Deer, RN, BSN, CNORCrystal Bouchard, RD,
  LDN

2
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

3
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

4
What is Morbid Obesity?

• Considered to be clinically severe. Morbid
  obesity is defined as
• gt200 of ideal weight or gt100 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
5
What Does Obesity Look Like or How Do We Measure
Obesity?
Based on 54 Female
Agency for Healthcare Research and Quality.
Screening for obesity in adults. Accessed June
22, 2010 from http//www.ahrq.gov/clinic/3rduspstf
/obesity/obeswh.htm Dugdale DC. Obesity.
MedlinePlus. Accessed June 22, 2010 from
http//www.nlm.nih.gov/medlineplus/ency/article/00
7297.htm
6
Morbid Obesity Trend An Epidemic within an
Epidemic
7
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.

Trust for America's Health and the Robert Wood
Johnson Foundation report "F as in Fat How
Obesity Threatens America's Future 2012."
8
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."
9
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 200328976." 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 20033481625."
10
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 28475-80
11
Co Morbidities Metabolic Syndrome
Central Morbid Obesity
Insulin Resistance
Complex interaction between genetic, metabolic,
and environmental factors
Recent studies suggest metabolic syndrome may be
an inflammatory state.
Hyper-Insulinemia
Dyslipidemia
Type 2 Diabetes
Hypertension
Heart Disease
Adapted from Lee YH, Pratley RE. The evolving
role of inflammation in obesity and the metabolic
syndrome. Curr Diab Rep. 2005570-75.
12
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.

13
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
• Its 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.
2006113898-918." 2Kenchaiah S, Evans JC, Levy
D, et al. Obesity and the risk of heart failure.
NEJM 2002 347305-313. "
14
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)

15
Impact of BMI on Longevity
Impact 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 2003289187.
16
Traditional Weight Loss Therapies
17
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

Type of Diet Completing One Year Weight 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.)
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 2005293(1)43-53.A
tkins is a registered trademark of Atkins
Nutritionals, Inc.Weight Watchers is a
registered trademark of Weight Watchers
International, Inc.
Program Name Date
18
Weight Loss of Various Treatments for Morbid
Obesity
Treatment Excess Weight Loss
Lifestyle / Pharmacologic Treatments1 (Diets, lifestyle programs, sibutramine, orlistat, rimonabant) lt10
Laparoscopic Adjustable Gastric Banding2 48
Sleeve Gastrectomy3 55
Gastric Bypass Surgery2 62
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. 20095469-475. Meta-analysis of
studies from 3 to 60 months followup.
19
Surgical Weight Loss Procedures

• Restrictive
• Laparoscopic Adjustable Gastric Banding
• Sleeve Gastrectomy
• Combination/Restrictive Malabsorptive
• Roux-en-Y Gastric Bypass
• Duodenal Switch / Biliopancreatic Diversion

20
Current Most-Used Bariatric Techniques
Vertical Sleeve Gastrectomy
Adjustable Gastric Banding
Roux-en-Y Gastric Bypass

• Malabsorptive Restrictive
• Bypass a portion of the small intestine and
  create a 15-30cc stomach pouch

• Restrictive
• Dissect approximately three-fourths of the
  stomach

• Restrictive
• Place implantable device around upper most part
  of stomach

21
Adjustable Gastric Banding

• Laparoscopic
• Least invasive
• Restrictive
• Mean excess weight loss of 482
• 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 2921724-37.
22
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)

23
Vertical Sleeve Gastrectomy

• Laparoscopic
• Restrictive
• Mean excess weight loss of 552
• 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. 20095469--475.
24
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

25
Roux-en-Y Gastric Bypass

• Can be laparoscopic
• Restrictive/Malabsorptive
• Most frequently performed bariatric procedure
• Mean excess weight loss at 1 year of 621
• No implanted medical device

1. Buchwald, H, Avidor Y, Braunwald E, et al.
Bariatric surgery A systematic review and
meta-analysis. JAMA. 2004 2921724-37
26
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

27
Advantages of Laparoscopic Roux-en-Y Gastric
Bypass

• Highest weight loss at 5 years
• Highest rate of resolution of other medical
  conditions 1
• Diabetes gt80
• High Blood Pressure gt65
• Seep Apnea 75
• High Cholesterol 65

1. Tice, J AJM2008 Vol 121, No 10, Gastric
Banding or Bypass ? A systematic review
28
Mean Excess Weight Loss 1 Year

• LAGB 48
• Sleeve Gastrectomy 55
• RYGB 62

29
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 19972006. J Gastrointest Surg.
2009 132292-2301 3Lie 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.
20081434338-344
30
BARIATRIC SURGERYLosing 50 to 70 of excess
weight1 may be just the beginning
31
Surgical Therapy for Morbid Obesity
32
Bariatric Surgical Candidate

• BMI gt35 with co-morbidities or gt40 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

33
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

34
The Bariatric Program at Bayhealth Surgeons --
Rahul Singh, M.D. -- Thomas Barnett, M.D. --
Assar Rather, M. D.
35
Bariatric Program Personnel

• Patty Deer, RN, BSN, CNOR Bariatric Program
  Coordinator
• Crystal Bouchard, RD, LDN - Dietitian
• Donna Hartzell, LPN - Office Coordinator

36
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.

37
Program Process Cont.

• All patients will be evaluated preoperatively by
  a licensed mental health provider. To ensure that
  patients ability to understand, tolerate, and
  comply with all phases of care and to ensure the
  patients 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-o
  p)

38
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

39
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

40
Nutrition Component

• SeminargtCoordinatorgtInitial consultation
• Most insurances require 6 month of dietitian
  monitored nutrition counseling.
• Months must be consecutive
• Must show constant steady improvement

41
Nutrition Component cont.

• Pt must follow a strict dietary lifestyle before
  and after surgery
• 11, or classes
• Food and nutrient education specific to procedure

42
Nutrition Component cont.

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

43
Nutrition Component cont.

• 4 week follow up
• Close follow up care/nutrition classes

44
References

• 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.
• Malhotra A, White DP. Obstructive sleep apnea.
  Lancet 2002360(9328)237-45.
• 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
  1993328(17)1230-5
• 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.
  20095469-475. Meta-analysis of studies from 3
  to 60 months followup.
• Buchwald H, Avidor Y, Braunwald E, et al.
  Bariatric surgery A systematic review and
  meta-analysis. JAMA 2004 292(14)1427-37
• Schauer PR, Ikramuddin S, Gourash W, et al.
  Outcomes after laparoscopic Roux-en-Y gastric
  bypass for morbid obesity. Ann Surg 2000
  232(4) 515-29
• 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.
• 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.
• Wittgrove AC, Clark GW. Laparoscopic gastric
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  results, with 3-60 month follow-up. Obes Surg
  2000 10(3) 233-9.
• 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)
  610-20
• 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.
• Surgerman HJ, Felton WL, 3rd, Sismanis A, et al.
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  associated with severe obesity. Ann Surg 1999
  229(5) 634-40 discussion 640-2.
• 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.
• Eid GM, Cottam DR, Velcu LM. Effective treatment
  of polycystic ovarian syhdrome with Roux-en-Y
  gastric bypass. Surgery for Obesity and Related
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