Sudbury Bariatric Regional Assessment & Treatment Centre

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1 Sudbury Bariatric Regional Assessment & Treatment Centre

2 Outline Obesity as a Chronic Disease 5 A s of Obesity Management OBN & BRATC Referral Process

3 Obesity Definition BMI Normal Weight Overweight Obese Class I Obese Class II (Severely Obese) Obese Class III (Morbidly Obese/Clinically Severe Obesity >40

4 Chronic Disease Associated with Obesity Heart disease Type 2 diabetes Cancers (endometrial, breast, and colon) Hypertension Dyslipidemia Stroke Liver and Gallbladder disease Sleep apnea and respiratory problems Osteoarthritis Gynecological problems (PCOS, infertility) Source:

5 The Cost of Obesity Obesity drives 60% of all chronic disease in Canada. A 2010 report estimated that direct costs of overweight and obesity represented $6 billion 4.1 % of Canada s total health care budget. However, this estimate only accounts for health care costs related to obesity, and does not account for productivity loss, reductions in tax revenues or psychosocial costs Source: Neil Seeman of the Health Strategy Innovation Cell at the University of Toronto

6 The Topic of Weight Scientific evidence does not support the long-term effectiveness of simple lifestyle advice, such as eat less and exercise more, in managing excess weight, especially in people living with severe obesity Source: Dr. Sara Kirk, Canada Research Chair in Health Services Research at Dalhousie University

7 The Topic of Weight Mounting evidence suggests more successful weight management outcomes are achieved via individualized interventions that take a holistic approach, delivered by a multi-disciplinary team of health professionals in a manner consistent with best practices in chronic disease management Source: Dr. Sara Kirk, Canada Research Chair in Health Services Research at Dalhousie University

8 The 5 As of Obesity Management Ask Assess Advise Agree Assist Source: Canadian Obesity Network

9 ASK for permission to discuss weight 1. Be non-judgemental 2. Explore readiness for change 3. Use motivational interviewing to move patients along the stages of change Source: Canadian Obesity Network

10 Sample Questions on How to Begin a Conversation About Weight: Would it be alright if we discussed your weight? Are you concerned about your weight? Would you be interested in addressing your weight at this time? On a scale of 0 to 10, how important is it for you to lose weight at this time? On a scale of 0 to 10, how confident are you that you can lose weight at this time? Source: Canadian Obesity Network

11 ASSESS obesity related risk and potential root causes of weight gain Assess obesity class & stage. Obesity Class (I-III) is based on BMI and is a measure of how BIG the patient is Obesity Stage (0-4) is based on the MEDICAL, MENTAL, and FUNCTIONAL impact of obesity and is a measure of how HEALTHY the patient is Source: Canadian Obesity Network

12 The Edmonton Obesity Staging System (EOSS) The Edmonton Obesity Staging System consists of the following five stages: Stage 0: Patient has no apparent obesity-related risk factors (e.g., blood pressure, serum lipids, fasting glucose, etc. within normal range), no physical symptoms, no psychopathology, no functional limitations or impairment of well-being. Source: Canadian Obesity Network

13 EOSS Stage 1: Patient has one or more obesity-related sub-clinical risk factors (e.g., elevated blood pressure, impaired fasting glucose, elevated liver enzymes, etc.), mild physical symptoms (e.g., dyspnea on moderate exertion, occasional aches and pains, fatigue, etc.), mild psychopathology, mild functional limitations and/or mild impairment of well-being. Source: Canadian Obesity Network

14 EOSS Stage 2: Patient has one or more established obesityrelated chronic diseases requiring medical treatment (e.g., hypertension, type 2 diabetes, sleep apnea, osteoarthritis, reflux disease, polycystic ovary syndrome, anxiety disorder, etc.), moderate functional limitations and/or moderate impairment of well-being. Source: Canadian Obesity Network

15 EOSS Stage 3: Patient has clinically significant end-organ damage such as myocardial infarction, heart failure, diabetic complications, incapacitating osteoarthritis, significant psychopathology, significant functional limitations and/or significant impairment of well-being. Source: Canadian Obesity Network

16 EOSS Stage 4: Patient has severe (potentially end-stage) disabilities from obesity-related chronic diseases, severe disabling psychopathology, severe functional limitations and/or severe impairment of well-being Source: Canadian Obesity Network

17 Assess Drivers, Complications & Barriers to Weight Management The 4Ms of Obesity Mental Cognition Depression Attention Deficit Addiction Psychosis Eating Disorder Trauma Insomnia Source: Canadian Obesity Network

18 Drivers, Complications & Barriers The 4Ms of Obesity MECHANICAL Sleep Apnea Osteoarthritis Chronic Pain Reflux Disease Incontinence Thrombosis Intertrigo Plantar Fasciitis Source: Canadian Obesity Network

19 Drivers, Complications & Barriers The 4Ms of Obesity METABOLIC Type 2 DM Dyslipidemia HTN Gout Fatty Liver Gallstones PCOS Cancer Source: Canadian Obesity Network

20 Drivers, Complications & Barriers The 4Ms of Obesity MONETARY Education Employment Income Disability Insurance Benefits Bariatric Supplies Weight-loss programs Source: Canadian Obesity Network

21 Root Causes Assess for Root Causes of Weight Gain Source: Canadian Obesity Network Is weight gain due to slow Metabolism? Age Hormones Genetics Low muscle mass Weight loss Medication Is weight gain due to increased Food intake? Socio-Cultural Factors Physical Hunger Emotional Eating Mental Health Issues Medication Is Weight Gain due to reduced Activity? Socio-Cultural Factors Socio-Economic Limitations Physical Limitations/Pain Emotional Factors Medication

22 ADVISE on obesity risks, discuss benefits & options Obesity Risks Explain Benefits of Modest Weight Loss Long-term strategy Treatment options Source: Canadian Obesity Network

23 Treatment Options Sleep, Time & Stress Dietary Intervention Low Calorie Diets Physical Activity Psychological Anti-Obesity Medications Bariatric Surgery Source: Canadian Obesity Network

24 AGREE on realistic weight-loss expectations and on a SMART plan to achieve behavioural goals Weight loss expectations Sustainable Behavioural Goals and Health Outcomes Treatment plan Source: Canadian Obesity Network

25 ASSIST in addressing drivers & barriers, offer education & resources, refer to provider, & arrange follow-up Drivers & Barriers Education & Resources Refer Follow-up Source: Canadian Obesity Network

26 Ontario Bariatric Network (OBN) Established in 2009 as part of the Ontario Bariatric Services Strategy initiated by the Ministry of Health and Long-Term Care of Ontario. OBN established 4 Bariatric Centres of Excellence (BCoE) in Hamilton, Toronto, Ottawa, and Guelph A BCoE is an organization with a team of experts promoting the collaboration and use of best practices around the care of people suffering with obesity and obesity related diseases. OBN established 4 Bariatric Regional Assessment and Treatment Centres (BRATC) in Windsor, Thunder Bay, Sudbury, and Kingston A BRATC like the BCoE is an organization with a team of experts promoting the collaboration and use of best practices around the care of people suffering with obesity and obesity related diseases. Unlike BCoEs, RATCs do not offer surgery. However, they are affiliated with a BCoE for surgeries

27 Bariatric Regional Assessment & Treatment Centre (BRATC) Sudbury s BRATC services an area of approx 400, 000km² NE Ontario, more than 550, 000 people, 60% urban, 40% rural Referral from MD or NP Referral is online through OBN Registry at Patients attend orientation, are booked for several assessments with our team of dietitians, social worker, psychologist, physiotherapist, nurse practitioner, physician Suitable surgical candidates meet with the surgeon on OTN Surgical candidates travel to Toronto to meet with surgical team & complete Optifast preparation Surgery is complete! Patient follows up at BRATC at 1, 3, 6, 12 months & yearly for 5 years

28 Healthcare Team Patient Surgeon Physician Your Primary Care Provider Nurse Practitioner/ Nurse Secretaries Social Worker Psychologist Physiotherapist Program Coordinator Pharmacist Registered Dietitian

29 Obesity and Bariatric Surgery Obesity prevalence is increasing 1 in 4 Canadians are obese Bariatric surgery A gastrointestinal surgical intervention which produces substantial weight loss Bariatric surgery has proven to be cost effective in treating co-morbidities i.e. diabetes, CAD Bariatric surgery has been proven to be more effective than conventional wt loss (-16 % vs +2%) at 10 years

30 Types of Bariatric Surgery Restrictive Adjustable Gastric band (Band) Restrictive and Malabsorptive Roux-en-Y Gastric Bypass (RYGB) Restrictive Vertical Sleeve Gastrectomy (VSG) Restrictive and Malabsorptive Biliopancreatic Diversion with Duodenal switch (BPD) page 30

31 Roux en Y Gastric Bypass Gold Standard Create small gastric pouch by stapling/sew (approx 10-30cc) Bring up the jejunum and attach to mini stomach Distal stomach, duodenum and proximal jejunum is left as a blind limb Laparoscopic/open Before After page 31

32 What is the Expected Weight loss with each surgery? In the first 1-2 years the average excess body weight (EBW) loss is: Roux-en-Y 50% to 75% Vertical Sleeve 33% to 58%

33 An Example of Expected Weight loss of the Roux-en-Y? A 300 lb person who is 5 5 would have a BMI of 50.5 They have lbs EBW They could lose lbs the first 1-2 years ( lbs) They will likely regain lbs in five years

34 So what impact does bariatric surgery have on chronic disease?

35

36 Questions?

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