Transcript Slide 1

Underwriting Obesity and
Bariatric Procedures
Nicola Charlton, MD.
Medical Director at Catholic Financial Life
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Venus of
Willendorf
• Statuette of female form circa 24,000 BC
• This idealized portrait was thought to
represent high status in a hunter-gatherer
society.
• Fat and nude meant fed and warm, as
opposed to starving and cold.
• It was an emblem of security and
success.
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Extra weight
was for years
considered
beautiful
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Obesity in Medical History
• Hippocrates wrote obese people died
suddenly and earlier compared to lean
• Charles Dickens in the Pickwick Papers
described obesity and an associated
condition: sleep apnea
• President Taft’s challenges with obesity
reported in Annals of Internal Medicine
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Genetics and Natural Selection
• Our biological tendencies to regulate body
weight at levels above our ideal weight
CANNOT be controlled
• This suggests that natural selection favored
FAT
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Western Abundance
• Never before has there been such an
abundance of rich, fatty foods and less
physical exertion
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The Role of Food Companies
• David Kessler, former FDA
Administrator, in his book “The End
of Overeating” suggests that food
companies cause addictions
because of their additives
• Much like cigarette companies use
the addictive agent nicotine, food
companies manipulate salt, fat, and
sugar levels in food - making them
more addicting
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High Fructose Corn Syrup
• HFCS significantly cheaper than real sugar
• Found in almost everything since 1976 when it
was approved by the FDA
• Princeton University study shows rats fed HFCS
with the same amount of calories as rats fed
natural sugars, have increased obesity and
greater abdominal obesity
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“Environment is the Real Cause of Obesity”
Director of Yale University, Center on Obesity Kelly Browning
Environmental Factors:
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Elevator
Moving sidewalk
Escalator
Computer/Video Games
Television
Automobiles
Riding Lawnmowers
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The Beginning of Suspected Problems
• While obesity was desirable and
beautiful in the past, the beginnings
of suspected problems are just a
few decades old
• It was around WWII that there has
been an increased understanding
that obesity was a risk for increase
mortality and the other problems
such as Hypertension
• Some of the first to understand this
were Life Insurance companies
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WWII era poster emphasizing the Basic 7 Food Groups
Metrics of Obesity
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Weight/Height
BMI
Waist Circumference
Body Composition - Bioelectric impedance
studies, DEXA, skin fold measurement
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Case Study - the applicant
• 55 year old Caucasian female
• 5’6” 220 lbs., BMI 34, BP 135/80, Waist 100 cm
• Past Medical History: Hypertension, dyslipidemia,
post-menopausal
• Social/Family- Married, works full-time, walks
daily
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Case Study – Underwriting factors
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Post-menopausal
Central obesity
Increased CV risk
Co-morbidities
Elevated BMI
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Case Study – Underwriting factors
• Family History - Mother d. MI age 60,
parents and siblings - obese
• Medications - Atenolol, Simvastatin, multivitamin
• Labs - A1C 6%, LDL 110, Cholesterol 240
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In 1943 Metropolitan Life Insurance
introduced their standard height-weight
tables for Men and Women
Height/Weight for Women
Height/Weight for Men
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Early Mortality Studies Based on
Met Life Weight Tables
• 1979 Norwegian study based on 4.2 million
policy holders insured by 25 U.S. and
Canadian Life Insurance Companies
• Most favorable mortality was 15% below to
5% above the desirable weight identified in
the Met Life height and weight table
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Actual Deaths to Actuarial Deaths
Relative Risk Mortality (RRM)
Women
Men
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History of Obesity as a Disease
• 1950s - Obesity was seen as a
personal responsibility issue
• 1980s - Public Health issue.
Obesity is a disease onto itself,
rather than just a risk factor for
HTN and Type 2 Diabetes
• 1990s - Obesity is seen as an
epidemic
McDonald’s starts in 1952
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Obesity is a Disease
• Obesity results in a multitude of chronic health issues
• The #1 Health problem in America
It was estimated
that up to 400,000
people may die
prematurely each
year due to obesity
related diseases
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Obesity is
a leading
cause of
preventable
death
worldwide
Leading causes of preventable death worldwide as of 2001, according to researchers
working with the Disease Control Priority Network and the World Health Organization
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Body Mass Index History
Developed in mid 19th century by Belgium
Socio-physicist as a measure of human
body shape based on height and weight
BMI =
2
kg/m
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Body Mass Index
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Met Life Tables and BMI
• J. Epidemiology 1991 from Department of Medicine, USC
• One of many papers that correlated the relative weight
derived from Metropolitan Life Tables to BMI to other
measures of fatness
• Found them to be very accurate and “nearly identical”
• Concluded that BMI is a very good estimate of fatness
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BMI and Adiposity
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Classification of Overweight and
Obesity by BMI
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Uneven Progress of Obesity
• Highest prevalence of obesity is among African
American women (53%)
• Followed by Mexican American women
40-59 years of age (51%)
• African Americans are 63% more likely to be
obese than non-Hispanic whites
• African Americans aged 40-59 years are 54%
more likely to be obese than those in the 20-29
year age group
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BMI and Race
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Waist circumference still used
• High Risk: Men >102 cm (>40 in)
• High Risk: Women >88 cm (>35 in)
• No predictive value of waist circumference
if BMI >35
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Waist ,BMI, Disease risk
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Prevalence of Obesity Today
• According to
NHANES (National
Health and Nutrition
Examination Survey)
61% of the U.S.
population is
classified as
overweight or obese
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Increasing BMI (1971-1999)
Largest among us have become much larger, with the
severely obese making up one of the fastest growing
segments of the obese population; increasing by 50-75%
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Obesity Trends Among US Adults
(BRFSS 2009)
BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person
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Childhood Obesity
• BMI > 95% for age & sex
• Tripled in the past 30 years
• 32% of children are overweight or obese
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Childhood Obesity
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Childhood Obesity
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Childhood Obesity
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Then and Now
In the 1950s, kids had three cups of milk for every
cup of soda. Today that ratio is reversed, meaning
they get all the calories and none of the nutrients
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Consequences of
Childhood Obesity
Common
• Growth
• Psychological
• Hyperlipidemia
• Hepatic Steatosis
• Abnormal glucose
metabolism
• Persistence into
adulthood
Uncommon
• Hypertension
• Sleep Apnea
• Pseudotumor
• PCOD
• Cholelithiasis
• Orthopedic complications
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Genetics and Morbid Obesity
• Children
– With normal weight parents
– Slight chance obesity
• Adopted children
– Show little correlation of body weight with
adoptive parents
– Show 80% correlation with genetic parents
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Adipocyte
The hyperplasia
and hypertrophy
of the fat cell is
the pathologic
lesion of obesity
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Physiological Impact of Obesity
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Obesity Related Health Care Costs
• 9% Total Medical Costs
• High Personal Costs: spend more money on
health care than smokers
• Direct National Cost: Treating obesity related
illness $61 billion
• Indirect Costs: i.e. missed work - $56 billion
• Disability: increasing disability
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Mortality and Obesity
New England Journal of Medicine, 1999
First Major Study Associating Mortality with Increasing BMI
•1 Million adults followed for 14 years, found relationship between BMI and risk of death
•White men and women- RR of death was 2.58 and 2.0 respectively at BMI > 24.9
•Greater BMI predictive of increased death from CVD, cancer, and all cause mortality
•Lowest rate of death from all causes between 23.5-24.9 kg/m2
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Mortality and BMI
U-shaped
curve for
BMI
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Mortality and Obesity
Nurses Health Study
• Risk of death increases progressively in women
with a BMI > 29kg/m2
• Mortality was lowest for women who weighed
15% less than the US average and whose
weight has been stable since early adulthood
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Mortality and Obesity
American Cancer Society Prevention Study I
Large groups of men and women followed for 14 years,
finding that greater BMI associated with increase rate of
death from ALL causes and from cardiovascular disease
in both men and women up to age 75
- Impact of increased body weight was higher among
younger study participants
- BMI.40kg/m2 Risk of death 2.6 times higher for men and
2 times higher for women
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Mortality and Obesity
American Cancer Society Prevention Study II
- Even larger study of men and women over 14 years,
showing the association of BMI and mortality was affected
by smoking status and history of other diseases
- Black men and women had lower risks than white men
and women
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BMI and Mortality Risk
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Obesity and Cardiovascular
Disease
CHD - Leading cause of mortality and morbidity in the US
770,000 Americans experience acute myocardial infarction
430,000 Americans experience recurrent cardiac adverse
events
BMI>35kg/m2 = 3 fold increase in all cause mortality and
cardiovascular mortality, but increase in death from CVD
related to confounding variable such as hypertension,
hypercholesterolemia, and diabetes
Obesity associated with increase of developing heart failure
and atrial fibrillation
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Obesity and Cardiovascular
Disease
Finnish Heart Study
Association between obesity and CVD
Study found that for each 1kg increase in
body weight, the risk of coronary mortality
increased by 1%.
A large number were medicated through high
blood pressure
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Obesity and Cardiovascular
Disease
Swedish Obesity Study
Followed 2 year incidence rates of new cases for
overweight individuals
Morbidities associated with increasing BMI
Increase HTN 15%
Increase Diabetes 7.8%
Increase Hyperinsulinemia 5.8%
Increase Hypertriglycerides 27.8%
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Obesity and Cardiovascular
Disease
Obesity mediated through inflammatory
process, such as C-Reactive Protein (C-RP)
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Relative Risk for Diastolic Blood Pressure,
Hypercholesterolemia and BMI
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Obesity and
Type II Diabetes Mellitus
- By 2025 worldwide prevalence of Type 2 Diabetes
estimated to be 300 million
- 90% who have Type 2 Diabetes are overweight
- Recent study reported a reduction of 8 years in
life expectancy in an individual who is diagnosed
with Diabetes by age 40
- 65% of patients who have Type 2 Diabetes die
from a cardiovascular event
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Age Adjusted Relative Risk of DM
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Obesity and Hypertension
Framingham Heart Study
79% of Hypertensive men and 65% hypertensive women
are overweight or obese
- Hypertension increases CHD risks and exacerbates
vascular complications including CAD, chronic kidney
disease, stroke, and peripheral vascular disease
NHANES III
Linear relationship between BMI and systolic and diastolic
blood pressure
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Obesity and Cancer
Overwhelming evidence that obesity
increases risk for certain cancers
– Breast cancer
– Colon cancer
– Uterine/Ovarian
Caused from increase levels of hormones
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Obesity and Metabolic Syndrome
National Cholesterol Education Program Adult Treatment Panel III
guidelines for diagnosing the metabolic syndrome
- Abdominal obesity defined as a waist circumference of 102 cm (40 in)
in men and 88 cm (35 in) in women
- TG levels of 150 mg/dL or more (1.7mmol/L)
- HDL-C levels of less than 40 mg/dL (1mmol/L) in men and less than
50mg/dL (1.30mmol/L) in women
- Blood Pressure levels of 130/85 mm Hg or higher
- Fasting glucose levels of 100 mg/dL or greater (5.5mmol/L)
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The Pathology of Excess Fat
Risks from Metabolic Changes
- DM
- Gallbladder Disease
- HTN
- CVD
- Some Cancers
Risks from increase weight
- Osteoarthritis
- Sleep Apnea
- Stigma of Obesity
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Effects of Overweight, Body Fat,
and Weight Gain on Mortality
Annual deaths attributable to obesity
280,000 – 325,000
with 80% of these deaths at BMI > 30kg/m2
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Cost of Co-morbidities attributable
to Obesity in the US
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Options for Treating Obesity
Non-surgical
Limited long-term success
- low calorie diets
- behavioral therapy
- exercise programs
- pharmacotherapy
Surgical
- Currently the best and most
successful method for sustained
weight-loss
- Has shown to substantially
improve or resolve any comorbidities: HTN, sleep apnea,
and Type 2 Diabetes
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Surgical Approaches to Obesity
• Weight loss surgery is the only effective treatment for
severe, medically complicated and refractory obesity.
• It does reverse, eliminate or significantly ameliorate
numerous life-threatening medical co-morbidities that
occur as part of pathophysiology of obesity
• Rapid changes in Surgical technique, technology, and
demand for weight-loss surgery has made it a dynamic
area of medicine
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Candidates for Bariatric Surgery
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BMI > 40kg/m2 - or - BMI > 35kg.m2 with significant obesity-related co-morbidities
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Acceptable operative risk
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Documented failure of nonsurgical weight-loss programs
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Psychologically stable with realistic expectations
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Well-informed and motivated patient
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Supportive family/social environment
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Absence of uncontrolled psychotic depressive disorder
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No active alcohol or substance abuse
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Bariatric Surgical Procedures
Malabsorptive
- Biliopancreatic diversion
Restrictive
- Vertical banded gastroplasty
- Adjustable gastric band
- Sleeve Gastrectomy
- Gastric balloon
Mixed Procedures
- Gastric Bypass or Roux -en- Y
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Malabsorptive Procedures
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Malabsorptive Procedures
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Weight loss from interference with normal physiologic absorption of nutrients by
structural changes of the GI tract
Very complex procedure
Rarely performed now because of severe problems with malnutrition
Improvement on this procedure was Duodenal Switch
– Minor part of the stomach was resected
– Part of the small intestine is connected to the new stomach pouch
Weight loss from interference with normal physiologic absorption of nutrients by
structural changes of the GI tract
Very complex procedure
Rarely performed now because of severe problems with malnutrition
Improvement on this procedure was Duodenal Switch
– Minor part of the stomach was resected
– Part of the small intestine is connected to the new stomach pouch
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Advantages
of Malabsorptive Procedures
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Very high weight loss
Very low risk of regain
98% type 2 diabetes mellitus resolved
99% hyperlipidemia resolved
83%hypertension resolved
No dumping syndrome/can be reversible
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Disadvantages
of Malabsorptive Procedures
• Life-long follow-up with blood tests
• High incidence of diarrhea
• Only select centers preform operations
because very complex and technical
• So many complications essentially
abandoned
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Vertical Banded Gastroplasty or
“Stomach Stapling”
• A band and staples are used to create a small pouch with
a small whole for food to flow to rest of the stomach
• Not used much anymore
• 80% of patients had some weight loss, but after 10 years,
only 10% had lost 50% of their excess weight
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Vertical Banded Gastroplasty
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Advantages of
Vertical Banded Gastroplasty
• No dumping syndrome
• No nutritional deficiencies or malabsorption
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Disadvantages of
Vertical Banded Gastroplasty
• Not reversible
• Strict compliance with diet or stomach
stretching and high caloric foods will
decrease weight loss
• Patient complaints of gastric reflux, nausea
and vomiting are common
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Adjustable Gastric Banding
• No malabsorption
• No maldigestion
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Advantages of
Adjustable Gastric Banding
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Less invasive than bariatric surgery
Lack of stomach stapling, cutting on intestinal re-routing
Absence of permanent changes to GI track
Reversible
Short operation and time in hospital stay
Fewer readmissions
Low Rate of early complications
Rarity of life-threatening complications
Low risk of nutritional deficiencies or malabsorptions
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Disadvantages of
Adjustable Gastric Banding
• Some changes in eating and disciplinary behavior
• Slower initial weight loss
• Regular follow-up for band adjustments is critical to
produce optimal results
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Complications of
Adjustable Gastric Banding
• GI perforation
• Pouch dictation from over-inflation of band or
excessive food intake
• Band slippage (gastric prolapse, herniation) due
to improper monitoring post-banding
• Band Erosion
• Port leakage or migration
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Successes of
Adjustable Gastric Banding
Weight loss- 3 large international trials have accumulated post-surgical
data showed average of 56% Excess Weight Loss (%EWL) which is
comparable to Roux-en-Y gastric bypass of 59%
Usually US studies show mean %EWL of:
- 53% at 36 months
- 52% at 48 months
- 54% at 60 months
- 57% at 72 months
Although AGB is good generally, Roxux-en-Y gastric bypass affords
greater weight loss
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Co-Morbidities Improved after
Adjustable Gastric Banding
Band system reduces or eliminates several
major co-morbidities:
• HTN
• Diabetes
• Sleep Apnea
• Hypercholesterolemia
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Sleeve Gastrectomy
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Sleeve Gastrectomy
• Functions by reducing stomach size
• Stomach becomes like a tube
• 80-85% of stomach removed
• Decreases production of Ghrelin (“Hunger
hormone”)
• Limited malabsorption
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Advantages of
Sleeve Gastrectomy
• Nerves to stomach and pylorus remain
intact
• Stomach function preserved
• Eliminates dumping
• Eliminates reactive hypoglycemia
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Disadvantages of
Sleeve Gastrectomy
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Sleeve leaking
Aversion to some foods with nausea
Possible gastroparesis
Esophogeal spasm and heartburn
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Gastric
Bypass
Roux-en-Y
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Roux-en-Y Gastric Bypass
• Gold Standard bariatric surgical procedure in US
• Most common by choice in American Bariatric surgeries
• Combination of gastric resection and variable reposition
of limb; either long limb resection or very very long limb
resection of roux limb to enhance weight loss
• Long-term EWL of 50-60% in 80% of patients
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Advantages of Roux-en-Y
• Commonly preformed- over 90% of WLS
• Improves obesity-related co-morbidities
and produces significant long-term weight
loss
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Disadvantages of Roux-en-Y
• Surgical complications, anastomotic leaks,
intestinal obstructions and hernias.
• Strictures
• Dumping syndrome
• Nutritional deficiencies
• Lifelong patient follow-up important
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Comparison of Surgical Procedures
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Risks of Bariatric Procedures
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Complications after
Bariatric Surgery
Study of insurance claims of 2,522 who had bariatric procedures
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22% had complications during initial hospital stay
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40% risk of complications in subsequent 6 months
Medical review of 16,1555 patients (Flum et al)
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30 day all cause mortality- 2.0%
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90 day all cause mortality- 2.8%
Age > 65 years, male sex, low surgery volume i.e. <25-30/year
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30 day all cause mortality- 4.8%
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90 day all cause mortality- 6.9%
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Malabsorptive Problems after
Bariatric Procedures
Protein deficiency (protein taken in goes to glucogenesis)
Need to replace EFA (fat soluble vitamins and EFA not absorbed)
Micro nutrients
• Iron: 32% in one survey had iron deficiency after one year
• B-12: 30% had defciciency even with supplementation
• Folate, B6, Zinc, Vit A, Vit E, Vit K, Magnesium, Thiamine
• Calcium and Vit D: all have some sort of metabolic bone disease. All
develop osteoporosis. Recent Mayo Clinic study showed fracture rate of
post bariatric patients significantly increased in the hips, spine and wrist.
Many have chronic skeletal pain and bone tenderness
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Benefits
Of Bariatric
Surgery
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Life Expectancy
“What Life Underwriters care about”
• Morbid obesity: an obese young adult with co-morbidities
and BMI over 45 has a 13 year shorter life-span
• Various articles all show improvement in many comorbidities, including recent discussion in NEJM articles
of Type 2 Diabetes as essentially resolved after bariatric
procedure
• Some studies show increased survival after 10 years in
some areas…
• But does bariatric surgical procedures improve mortality?
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Long-Term Mortality after
Gastric Bypass
NEJM: Retrospective cohort study of approximately 8,000
surgical patients with bariatric bypass and 8,000 controls
• After 7 years, long term mortality decreased by 40%
• 37 deaths per 10,000 vs. 57 deaths per 10,000
• Cause specific death decreased
CAD (2.6 vs. 5.9/10,000) – 56%
DM (.4 vs. 3.4/ 10,000) – 92%
CA (3.5 vs. 13.3/10,000) – 60%
• Deaths from accidents & suicide were higher in surgery
group than in control group (11.1 vs. 6.4/10,000- 58%)
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Challenges of Bariatric Outcomes
• No long term mortality studies
• No standardization of success or failure
- Most studies consider 50% of excess weight-loss “success”
• Few agreed-upon measures of outcomes
• No agreement on what is a major or a minor surgical complication
• No consistent agreement of what constitutes an early surgical
complication or a late complication (some studies do not even
consider re-operation a complication)
• Studies are difficult due to lack of consistent follow-up by patients,
patients switching health providers, health insurance changes, and
follow up with different providers
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What’s Ahead - Medications
Medical treatment of obesity
• Lorcaserin
– Trade name: Belviq
• Phenteramine/Topiramine
– Trade name: Qsymia
• Both approved BMI > 27 with comorbidities
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Lorcaserin
• Selective Serotonin Receptor Agonist - 5HT
receptor
• Appetite and weight reducing effect of serotonin
are thought mediated by 5HT receptor in brain
• Side Effects/warnings: Valvular heart disease
• Cognitive impairment
• Depression and suicidal thoughts
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Phenteramine/Topiramate
• 2 old drugs packaged together
• Teratogenicity- only prescribed through central
pharmacy
• Lots of Side Effects/warnings
• Mood changes, cognitive disorders, suicidal
ideation, increased Creatinine, metabolic
acidosis
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Orlistat
• FDA Approved in 1999
• Interferes with the absorption of
fats in the intestines
• Numerous clinical trials show efficacy and safety
• Often used in Metabolic Syndrome and Major
Type 2 Diabetes Mellitus
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Obesity Drugs in the near future
and on the distant horizon
Rimonabant – Cannabinoid receptor block
- 1 receptor antagonist
- Marijuana stimulates Cannabinoid receptors and causes increase in
high-fat, high-sweet foods. This drug blocks Cannabinoid receptors.
- Several major studies will be out soon (approved in Europe)
Leptin – Leptin hormone-modulator
- Lack of Leptin (derived from fat cells) causes massive obesity, replacement
of Leptin reduces weight
- Studies focus on a general treatment of obesity
Axokine – Neurotransmitter, histamine
- 3 antagonists: brain energy and sensing modulations -product of fat cells
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- Originally used for ALS, found to cause loss of appetite
Obesity Drugs in the near future
and on the distant horizon
Ghrelin
- Hunger regulating hormone produced in stomach and pancreas
- Receptors in many tissues also found associated with dopamine
levels and thus stress, depression, sleep issues
- Levels decrease significantly after gastric bypass , possible vaccine
or medication targeted at receptors
- Medication binds to targeted receptors. Prevents Ghrelin from
binding with receptors and reaching the CNS, which prevents weight
gain
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Pharmaceutical companies looking for
antagonists to inhibit food intake
- Numerous peptides in stomach and small
intestine that are released to restrain
consumption and minimize postprandial glucose
- Gastrointestinal signals seem to respond to
macronutrients consumed
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Exercise and Diet
• Backbone of Obesity Treatment (before
and after surgery) is still Exercise and Diet
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Now back to our Applicant
• Weight history
• Over weight child or as a young adult?
• Co-morbidities and duration of them?
• Additional problems:
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tobacco
exercise
psychological history
alcohol history
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Pregnancy after Bariatric surgery
• Weight loss does help fertility
• Reduced rate of gestational diabetes, HTN, pre-eclampsia
and macrosomia
• Complications increase – risk of intestinal obstruction or
other surgical emergencies. One study had 3 maternal deaths and
5 neonatal deaths from these surgical emergencies.
• Increase risk of growth retardation of neonate or low birth
weight
• Treat all pregnant women after bariatric surgery as a highrisk pregnancy
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Checklist for Underwriters
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BMI
Waist circumference
Co-morbidities and duration of them?
Any secondary causes or medications?
Bariatric procedure
• Type of procedure and location?
• Follow-up and regular blood work?
• Co-morbidities resolved or improved?
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Underwriting is an Art and Science
• Applicant, and others like her, have many
variations on similar themes, but many
decisions involve an interplay of factors
and subtle differences that only an
experienced Underwriter can ascertain.
• Mortality increasingly found linked to many
social determinants and not medical ones.
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Determinants of Health
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The End
I’m not over-weight, I’m under-tall.
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