Transcript Sleep-symposium-ppt-2013

The Impact of Obesity and its
Treatment Options
Bayhealth Bariatric Program
Rahul Singh, MD
Patty Deer, RN, BSN, CNOR
Crystal Bouchard, RD, LDN
What are you going to learn today?
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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?
Overweight
Normal Weight
(BMI 19 to 24.9) (BMI 25 to 29.9)
Obese (Class II)
(BMI 35 to 39.9 )
Morbidly Obese
(BMI 40 or more)
175#
BMI 30
205#
BMI 35
234#
BMI 40
Based on 5’4” Female
Obese (Class I)
(BMI 30 to 34.9)
130#
BMI 22
152#
BMI 26
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/007297.htm
Morbid Obesity Trend: An “Epidemic
within an Epidemic”
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."
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 obesityrelated 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
•Gastroesophageal reflux disease
•Hypertension1,3
(GERD)2,3
•Hyperlipidemia1,3
•Degenerative joint disease (DJD)3
•Respiratory disease1,3
•Heart disease 2
•Sleep apnea1,2,3
•Gallstones1,2,3
•Depression3
•Fatty liver disease2,3
•Menstrual irregularity2
•Coronary artery disease1,3
•Amenorrhea2
•Stroke1
•Dysmenorrhea2
•Osteoarthritis1,2
•Urinary stress
•Infertility2
incontinence3
•Metabolic Syndrome
•Asthma/pulmonary
1. NHLBI 2000 (NIH), Practical Guide: Identification, Evaluation and Treatment of Overweight
disorder2,3
and Obesity in Adults
2. NIDDK 2006 (NIH), Understanding Adult Obesity.
•Cancer1,3
3. Schneider BE & Mun EC. Diabetes Care. 2005; 28:475-80
Co Morbidities: Metabolic Syndrome
Central Morbid Obesity
Complex interaction between
genetic, metabolic, and
environmental factors
Insulin Resistance
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. 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 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 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)
Weight Loss at One
•Medically
Type of Diet supervised
Completing One Year
Year
•Each
the
LDL/HDL 2.1
ratio
Atkins® diet reduced
21/40
(53%)
kg (4by
lbs.)10
percent
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 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.
Program Name | Date
Weight Loss of Various Treatments for
Morbid Obesity
Treatment
Lifestyle / Pharmacologic Treatments1
(Diets, lifestyle programs, sibutramine, orlistat,
rimonabant)
Excess
Weight Loss
<10%*
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.
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;5:469475. Meta-analysis of studies from 3 to 60 months followup.
2Buchwald
Surgical Weight Loss Procedures
Restrictive
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Laparoscopic Adjustable Gastric Banding
Sleeve Gastrectomy
Combination/Restrictive & Malabsorptive
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Roux-en-Y Gastric Bypass
Duodenal Switch / Biliopancreatic Diversion
Current Most-Used Bariatric Techniques
Adjustable Gastric
Banding
Vertical Sleeve
Gastrectomy
Roux-en-Y Gastric
Bypass
Restrictive
Restrictive
Malabsorptive &
Restrictive
Place implantable
device around upper
most part of stomach
Dissect approximately
three-fourths of
the stomach
Bypass a portion of the small
intestine and create a
15-30cc stomach pouch
Adjustable Gastric Banding
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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 metaanalysis. JAMA.
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2004; 292:1724-37
Potential Risks and Complications of
Gastric Banding
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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
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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
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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
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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
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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; 13:2292-2301
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. 2008;143[4]:338-344
BARIATRIC SURGERY
Losing 50% to 70% of excess weight1 may be just the beginning…
Surgical Therapy for Morbid Obesity
Bariatric Surgical Candidate
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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
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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
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Informational Seminar Attendance (Mandatory)
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Verify benefits and obtain insurance authorization
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Initial consultation with Program Coordinator and Surgeon
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Nutritional evaluation & counseling with our dieticians
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Psychological evaluation
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Sleep Study and Pulmonary Clearance
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Cardiology Clearance
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Primary Care Clearance
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Support Group attendance
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Pre-operative testing (Labs, EGD, UGI)
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Surgery
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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.
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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
References
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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 2002;360(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 1993;328(17)1230-5
1Bray GA. Lifestyle and pharmacologic approaches to weight loss: Efficacy and safety. J Clin Endocrinol Metab, 2008; 93(11): 581588.
2Buchwald H, Avidor Y, Braunwald E et al. Bariatric surgery: A review and meta-analysis. JAMA 2004; 292(14):1724-1737. Metaanalysis 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.
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 bypass, Roux-en-Y – 500 patients; technique and 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. Gastric surgery for pseudotumor cerebri 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 Diseases 2005; 1:77-80.