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1 The weight of the world. SONY ANTHONY

2 Obesity Derived from the Latin word obesus to devour Definition: having a very high amount of body fat in relation to lean body mass Classifications using Body Mass Index (BMI)

3 Classification using BMI <18.5 Underweight Normal lweight Overweight Obesity Class I Obesity Class II Obesity Class III Asians: increased risk 23 to <27.5 K/ Kg/m 2, and high risk 27.5 Kg/m 2

4

5 Obesity trends among US adults

6 Problem in UK

7 Adult obesity

8 Adult obesity

9

10

11 Source: National Heart Forum: micro simulation of Obesity Trends

12 Comorbidities with obesity Type 2 Diabetes Hyperlipidemia Hypertension Obstructive Sleep Apnea Heart Disease Stroke Asthma Back and lower extremity weightbearing degenerative problems Cancer Depression AND MORE!

13 Risks due to obesity Men Women 5 X T2DM 13 X T2DM 3 X Ca colon 4 X HTN 2.5 X HTN 3 X IHD

14 Direct cost to NHS: 5.1bn Wider cost to economy: 16bn Source: DoH; Facts and figures on obesity

15 Management: Lifestyle changes Diet Physical activity Pharmacological management Bariatric surgery

16

17

18 Pharmacological l Treatment Must use drugs with online / phone support packages AND reducing diet plus exercise

19 Bariatric surgery history 1950s: initial attempts 1954: Jejuno-ileal l bypass by Kremen and associates 1967: first gastric bypass surgery 1980s: Adjustable gastric band

20 Gastric Banding General Features Inflatable balloon within the band orifice, adjusted via a reservoir under the skin Average Weight loss 40-50% of Excess weight

21 Sleeve Gastrectomy General Features Pouch ml 150ml Quick emptying of stomach Independent procedure First step in high risk and extremely obese pt Average Weight loss 50-60% of Excess weight

22 Gastric Bypass General Features Pouch size- 50ml Pouch opening 1/2in RNY limb- 50cm BP limb- 100cm Average weight loss 60-70% excess weight

23 Biliopancreatic diversion with duodenal switch General Gastric pouch size: Standard: 150ml Three segments Alimentary tract: 6.5 ft Biliary tract: 13 ft Common channel: 1.5 ft Average weight loss 80% excess weight

24

25

26 Does it work?

27

28 Efficacy of Bariatric Surgery for Weight Loss Mean percentage excess weight loss: 61.2% - All Patients 47.5% - Gastric Banding 61.6% - Gastric Bypass 68.2% - Gastroplasty 70.1% - BPD or duodenal switch *Buchwald H, et al. Bariatric Surgery: A Systematic Review and Meta-analysis. JAMA, 14: , 2004

29 Effect on Comorbid Conditions Diabetes 76.8% - Completely resolved 86.0% - Resolved or improved Hyperlipidemia 70% - Improved HTN 61.7% - Resolved 85.7% - Resolved or improved Obstructive Sleep Apnea 83.6% - Resolved 85.7% - Resolved or improved Buchwald H, et al. Bariatric Surgery: A Systematic Review and Metaanalysis. JAMA, 14: , 2004

30 Schauer et al; Arch Surg. 2010;145(1):57-62

31 Results. At 2 years Diabetes remission None in the medical group 15 out of 20 (75%) in gastric bypass group 19 out of 20 (95%) in biliopancreatic diversion i group p<0.001 for both surgical groups as p g g p compared to medical therapy

32 Limitations of this study Sample size small Large multicentre studies needed The study does not show long term out come eg rate of deaths, cardiovascular events or differences in the long term morbidity between two surgical procedures Eligibility ibili criteria i did not include cuts off fffor dyslipidaemia and arterial blood pressure

33 Is surgery the universal panacea??? All studies so far have been small & short term Will the results of bariatric surgery be as good in routine practice? There are also potential long-term problems from micronutrient deficiencies Some patients are also unable to cope psychologically

34 NICE guidelines Bariatric surgery is recommended as a treatment option for adults with obesity: BMI of > 40 Kg/m 2 35 Kg/m 2 to 40 Kg/m 2 and other significant disease First-line option if BMI > 50 Kg/m 2 in whom surgical intervention is considered appropriate.

35 NICE guidelines non-surgical measures have been tried but have failed to achieve or maintain adequate, clinically beneficial weight loss for at least 6 months the person has been receiving or will receive intensive management in a specialist obesity service the person is generally fit for anaesthesia and surgery the person commits to the need for long-term follow-up

36 Source: Shedding the Pounds - Obesity Management, NICE Guidance and Bariatric Surgery g y g, g y In England, published by Office of Health Economics

37

38 He alone can remain healthy, who regulates his diet, exercise and recreation, controls his sensual pleasures, who is generous, just, truthful and forgiving, and who gets along well with his relatives. Ayurveda BC

39 People should eat chocolate ice-cream instead of killing each other. John Roderick, journalist and China expert. (1914- March 11, 2008)

40

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