Definition of Obesity. Weighing Your Options. The Time Is Now For Bariatric Surgery. Presented By Dr. Joseph Martin.

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1 The Time Is Now For Bariatric Surgery Presented By Dr. Joseph Martin The St. Elizabeth and St. Joseph Surgical Weight Loss Center Center of Excellence In Bariatric Surgery St. Elizabeth and St. Joseph Surgical Weight Loss Center 452 Broadway Street Youngstown, OH Weighing Your Options Overview of obesity Treatment of obesity Different Types of Weight Loss Surgery Bariatric Diets and Supplements Surgical Weight Loss Center of Excellence Program Questions and Answers? Definition of Obesity Ideal Body Weight Obesity is about 30 pounds over ideal body weight Morbid Obesity defined as 100 pounds or more over ideal body weight Excess Body Weight Difference between ones ideal weight and their actual weight 1

2 IDEAL BODY WEIGHT Metropolitan Life Insurance Company Height/Weight Chart Woman Revised 1983 Men Height Small Feet Inches Frame Medium Large Frame Frame 4' 10" ' 11" ' 0" ' 1" ' 2" ' 3" ' 4" ' 5" ' 6" ' 7" ' 8" ' 9" ' 10" ' 11" ' 0" Height Small Feet Inches Frame Medium Large Frame Frame 5' 2" ' 3" '' 4" ' 5" ' 6" ' 7" ' 8" ' 9" ' 10" ' 11" ' 0" ' 1" ' 2" ' 3" ' 4" Definition of Obesity BMI = Weight (kg) / Height (m2) Definition of Obesity based on BMI Normal -BMI Overweight -BMI Obesity -BMI Morbid Obesity -BMI > 40 Obesity rates: Current and projected Population percentage with BMI > 30 kg/m USA England Mauritius Australia Brazil

3 Frequency of Obesity by State 2004 vs 2013 CDC Data #1 Mississippi % (Obese state) #2 Alabama % #3 West Virginia % #11 Ohio % #19 Pennsylvania % #50 Vermont % #51 Massachusetts % #52 Colorado % (Thinnest state) #1 Mississippi and West % (Obese state) Virginia (Tied) #2 Arkansas % #3 Tennessee % #15 Ohio -30.4% #17 Pennsylvania % #40 Massachusetts % #41Hawaii % #42 Colorado % (Thinnest state) Note: Data included District of Columbia (D.C.), Puerto Rico, & Virgin Islands and no data available on Hawaii so 52 states listed Impact of Obesity Quality of Life Comorbid Diseases Obesity Disability Mortality Medical Cost Obesity Related Co-Morbidities Diabetes Mellitus Hypertension Elevated Cholesterol and Triglycerides Sleep Apnea GERD Coronary Artery (Heart) Disease Degenerative Joint Disease Urinary Incontinence (Leakage of Urine) Peripheral Edema Chronic Venous Insufficiency Depression Asthma 3

4 Scope of Problem of Obesity Incidence 1/3 of the US Adult Population is obese (34.9% or 78.6 million U.S. Adults are Obese) 15% morbidly obese 17% of children and adolescents are obese (12.5 Million) 400,000 die annually from obesity related comorbidities $147 billion annual cost in health care and lost productivity Etiology of Obesity Factors related to obesity Genetic Hormonal Environmental Increase availability and decreased cost of food Decrease activity Energy Balance Intake is More Expenditure Less = Weight Gain Intake is Less Expenditure is More = Weight Loss Intake = Expenditure Weight Maintenance 4

5 10% Weight Loss Improves Overall Health Blood Cholesterol Blood Glucose Blood Pressure A Guide to Selecting Treatment Treatment > 40 Diet, Physical Activity, and Behavior Therapy With Co- Morbidity Pharmacotherapy With Co- Morbidity Surgery With Co- Morbidity + Brief History of Weight Loss Surgery Jejunal-ileal bypass Gastric bypass Biliopancreatic diversion Gastric partitioning Roux-en-Y Gastric Bypass (RYGB) Vertical banding gastroplasty Duodenal switch procedure Laparoscopic RYGB 2001 Laparoscopic Gastric Band Gastric Stimulator (Experimental) 2003 Laparoscopic Sleeve Gastrectomy 5

6 Criteria for Eligibility for Bariatric Surgery National Institute of Health (NIH) Criteria based on 1991 consensus statement BMI > 40 Patient failed medical therapy Patient aware of the significant risk of the surgery, required changes in diet, and desires surgery BMI >35 & < 40 In addition to the above, patient has 2 significant obesity related comorbidities Currently Performed Weight Loss Surgeries Roux-en-Y Gastric Bypass most common Laparoscopic Gastric Band Laparoscopic Sleeve Gastrectomy - newest treatment Before gastric bypass surgery After gastric bypass surgery Carnie Wilson Singer (RYGB 1999) 6

7 Al Roker NBC Today morning weatherman 2002 Gastric Bypass Surgery Randy Jackson American Idol judge 2003 Gastric Bypass Surgery Mechanism of Action of Bariatric Surgical Procedures Restriction of Functional Capacity of the Stomach Malabsorption of food ingested Combination of above Roux-en-Y Gastric Bypass or RYGB (1979) The most widely performed and accepted bariatric surgical procedure in the U.S. 7

8 Roux-en-Y Gastric Bypass or RYGB (1979) Severe Gastric restriction Malabsorption Behavioral Modification Dumping Syndrome 8

9 St. Joseph Health Care Center Warren, Ohio Laparoscopic RYGB (1994) 5 small incisions Advantages Less pain and wound complications Quicker recovery 24 Hour Observation Hospital Stay 75% EBWL Laparoscopic procedure, wrapping the lap band around upper stomach to form a 30 ml to 50 ml pouch Band connected to a port under the skin to inject or withdraw fluid to inflate or deflate band Purely restrictive procedure, no malabsorption 50% EBWL Lap Band (2001) 9

10 Laparoscopic Sleeve Gastrectomy Removal of the remaining stomach Pouch 3oz. to 4oz. in size Purely restrictive procedure, no malabsorption 50-60% EBWL Process for Evaluation & Scheduling for Weight Loss Surgery at SWLC Schedule Initial Consultation Visit and Fill Out Necessary Paperwork At the Initial Consultation Meet with the Bariatric Nurse Meet with the surgeon who performs History & Physical and explains the different surgeries right for you. Based on patient needs further testing will be scheduled at this time. Process for Evaluation & Scheduling for Weight Loss Surgery at SWLC Nutrition Consultation with the Surgical Weight Loss Bariatric Dietitian Insurance Companies Dietary Requirements needs met Psychological Evaluation Upper GI Endoscopy (scope test) Ultrasound of the Gallbladder (if still present) Cardiac Clearance Pulmonary Clearance (Based on Past Medical History) Medical Clearance Insurance Submission and Approval 10

11 Process for Evaluation & Scheduling for Weight Loss Surgery at SWLC 2 Hour Nutrition Class Preoperative H & P (within 30 days of surgery) Preadmission Testing (within 10 to 14 days of surgery) Surgery is 24 Hour Observation Before Surgery Dietary Requirements: 10% of Excess Body Weight Lost Before Surgery Super Morbidly Obese patients need to work with RD/LD to maintain a healthier weight before surgery. Some Insurance companies require 6 months weight loss and exercise program prior to surgery Before surgery patients must purchase a 3 month supply of Bariatric Approved Vitamins, Calcium and Protein Supplements to be used after surgery. The Difference Purely Restrictive Laparoscopic Gastric Band Laparoscopic Sleeve Gastrectomy Restrictive, Malabsorption and Behavior Modification Roux-en-Y Gastric Bypass Surgery 11

12 Create a Small Pouch - Restriction Patients have to learn that they need To eat to live after bariatric surgery not Live to eat. The first realization is that they can only eat a very small volume of food and that this is okay and satisfying. Control of hunger and fullness. This is the biggest obstacle RYGB Lifestyle for Eating Mechanisms of Weight Loss Create a Small Pouch Malabsorption Dumping Syndrome Malabsorption If patients choose to have the Roux-en- Y Gastric Bypass Surgery. They have the benefit of not absorbing all the calories, fat, protein, vitamins, minerals and nutrients that they consume for the first months post-op. 12

13 Dumping Syndrome Behavior Modification Sugar Fats Symptoms Prevention Rules of 2 PROTEIN Grams Importance of Protein Protein Deficiency Protein Supplementation Lifestyle Habits after Bariatric Surgery 6 small meals daily 1200 calories daily 3oz. to 4oz. portions daily 25gms. - 35gms. fat daily 60gms. - 80gms. protein daily - Males 80gms. 64oz. - 90oz. fluid daily Chew times per bite Add 1 new food item at a time 13

14 Diet Progression Bariatric Clear Liquid Diet Bariatric Full Liquid Diet Bariatric Puree Diet Bariatric Soft Diet Regular 1200 Calorie Diet Behavior Modification Lactose Intolerant Red Meats, Doughy and Fibrous Foods Carbonated Beverages Decaffeinated Coffee, Decaffeinated Tea Alcoholic Beverages Juices Low Sugar, Low Fat Diet Supplements Bariatric Approved Multi-Vitamins Daily (2 to 4 times) mg Calcium Citrate with 1000iu of Vitamin D Gastric Sleeve patients will also take an additional Vitamin B 12 supplement If your Multi-Vitamin does not contain Iron you will take an additional Iron Supplement Vitamin D3 5,000iu every other day Iron Supplements as needed Check Labs - 2wk, 6wk, 3m, 6m, 1 yr, 18m, Yearly 14

15 Difficulties: Excess Salvia -Food Getting Stuck Food Bezoar Delayed Dumping Syndrome - Reactive Hypoglycemia Constipation Gas - Floating Stools Weight Regain - 18 months post-op Bariatric Surgery 20% Clinical 80 % Patient Behavior Change Alternative to Eating Stress Management Regular Physical Activity 15

16 Lifestyle Change This is a diet patients will need to follow for a life time. Patients will always need to watch calories, fat intake, and portion control. Patients will always need to exercise. Patients will always need to take vitamins and supplements Patients will need to return for routine follow-up yearly Advantages and Outcomes of Bariatric Surgery Effective weight loss in morbidly obese patients Improvement in obesity related comorbidities Diabetes, High Blood Pressure, High Cholesterol, High Triglycerides, Sleep Apnea - Resolve Improved Quality of Life Decreased Long-term Health Care Cost St. Elizabeth and St. Joseph Surgical Weight Loss Center Surgery Cases - Since Total Surgery Number is 1,555 Monthly Bariatric Surgeries Yearly Average Surgeries

17 Weight Loss After RYGB Surgery Weight Loss- varies from patient to patient Approximately 90% of patients will loose at least 50% of their excess weight. Expected rate of excess weight loss 33% at 3 months 65% at 12 months 75% at 18 months Weight Loss Results at St E/St J SWLC Wt. Lost Benchmark % EBWL (Lbs.) 3 33% 41% % 73% % 75% 111 SWLC Weight Loss Results Reduction in BMI 242 cases 30 Days 6 Months SWLC Nat. Data SWLC Nat. Data Year 2 Year SWLC Nat. Data SWLC Nat. Data Note: In Red is the SWLC BMI reduction data and you can see where we are ahead of the national average. 17

18 Obesity Related Co-Morbidities Diabetes Mellitus Hypertension Elevated Cholesterol and Triglycerides Sleep Apnea GERD Coronary Artery (Heart) Disease Degenerative Joint Disease Urinary Incontinence (Leakage of Urine) Peripheral Edema Chronic Venous Insufficiency Depression Asthma Improvements in Obesity-Related Co- Morbidities, St E / St J SWLC Preop Average 12.8 month F/U Incidence Resolved Improved HTN 241 (60%) Hypercholest erolemia 170 (42%) Diabetes 120 (30%) Obstructive Sleep Apnea 66% 26% 61% 19% 70% 30% 96 (24%) 75% 21% SWLC Leak Rate 327 Cases 30 Days 6 Months SWLC Nat. Data SWLC Nat. Data 0.8% 0.3% 0% 0.1% 1 Year 2 Year SWLC Nat. Data SWLC Nat. Data 0% 0% 0% % Note: In Red is the SWLC Leak Rate data and you can see where we are ahead of the national average. Our Average leak rate is 0.3% and you want you leak rate to be less than 1.0% in order to be a Center of Excellence. 18

19 FOLLOW- UP 6 wks SWLC Improvement in Quality of Life No. pts. 376 Greatly improved 35% Change in QOL Compared to Preop Improved 46% Same 14% Diminished 4% Greatly diminished 1% 3 mos % 33% 3% 1% 0% 6 mos % 20% 1.5% 1% 0.5% 12 mos % 15% 2% 1% 0% 18 mos % 10% 1% 2% 0% 24 mos 60 80% 11% 7% 2% 0% Ht 5 1 Wt 302 lbs Excess BW 177 lbs BMI year after RYGB Wt lost 124 lbs EBWL 72% BMI year-old female Ht Wt lbs Excess BW 94 lbs BMI mo follow-up Wt 110 lbs Wt lost 90 lbs %EBWL 96% BMI

20 Ht 6 0 Wt 309 lbs Excess BW 121 lbs BMI year after RYGB Wt lost 113 lbs EBWL 93% BMI 26 Off CPAP HTN resolved Knee pain resolved Back pain improved 34 year-old female Height 5 5 Weight 268 lbs BMI 44 Excess BW-128 lbs 31 months after RYGB Weight 143 lbs Wt. Loss 126 lbs %EBWL 98% BMI year-old female Height 4 11 Wt 202 lbs BMI 40 Excess BW 92 lbs 24 months after RYGB Wt 119 lbs Wt. Loss 81 lbs %EBWL 90 % BMI 24 Resolved: HTN, DM, & high chole/trig 20

21 49 year-old female Height 5 3 Weight 307 BMI 54 Excess BW lbs 10 months after RYGB Weight 187 Wt. Loss 120 lbs %EBWL 75% BMI 33 Medical Problems Improved: HTN, OA, LBP, GERD Ht 5 4, Wt 274 lbs Excess BW 136 lbs BMI years after RYGB Wt 156 lbs Wt lost 118 lbs EBWL 87% BMI year-old female Height 5 3 Weight 284 lbs BMI 50 Excess BW lbs 1 yr after RYGB Weight 151 lbs Wt. Loss 133 lbs %EBWL 89% BMI 26 21

22 49 year-old male Height 5 10 Weight 300 lbs BMI 43 Excess BW-116 lbs 1 yr after RYGB Weight 189 lbs Wt. Loss 114 lbs %EBWL 96% BMI 27 Before 2 ½ years after RYGB Weight 182 lbs Wt. Loss 121 lbs %EBWL 104% BMI year-old female Ht Wt lbs BMI 52 Sleep apnea with tracheostomy RYGB 5/19/ month follow-up Wt lost - 69 lbs Tracheostomy removed and sleep apnea resolved 18 mo follow-up Wt 184 lbs Wt lost 127 lbs %EBWL 75% BMI

23 Ht 5 5, Wt 282 lbs Excess BW 152 lbs BMI year after RYGB Wt 170 lbs Wt lost 112 lbs EBWL 74% BMI year-old female Ht Wt lbs Excess BW 107 lbs BMI 42 6 mo follow-up Wt 158 lbs Wt lost 88 lbs %EBWL 75% BMI year-old female Ht Wt lbs Excess BW 109 lbs BMI 41 6 mo follow-up Wt 138 lbs Wt lost 92 lbs %EBWL 83% BMI

24 41 year-old female Height 5 1 Weight 259 lbs BMI 49 Excess BW- 139 lbs 3 years after RYGB Weight 147 lbs Wt. Loss 113 lbs %EBWL 81% BMI 28 Decreased: Arthritic pain Dyspnea Ht 5 1 Wt 252 lbs Excess BW 127 lbs BMI months after RYGB Wt lost 121 lbs EBWL 95% BMI 25 Sleep apnea resolved Decreased back pain Increased energy 41 year-old female Height 5 7 Weight 277 lbs Excess BW 130 lbs BMI 43 3 years after RYGB Weight 146 lbs Wt. Loss 131 lbs %EBWL 101% BMI 22 24

25 39 year-old male Height 5 1 ½ ; Weight 350 lbs Excess BW- 165 lbs; BMI 48 1 year after RYGB Weight 232 lbs; Wt. Loss 118 lbs %EBWL 73% ; BMI year-old female Height 5 7 Weight 254 lbs Excess BW 116 lbs BMI 40 2 years after RYGB Weight 155 lbs Wt. Loss 99 lbs %EBWL 85% BMI year-old female Height 5 5 Weight 224 lbs BMI 37 Excess BW- 97 lbs 1 year after RYGB Weight 132 lbs Wt. Loss 5 lbs %EBWL 95% BMI 22 Resolved: HTN Hypercholesterolemia Hypertriglyceridemia 25

26 30 year-old male Ht Wt lbs Excess BW 198 lbs BMI 54 1 year after RYGB Wt 191 lbs Wt lost 187 lbs %EBWL 94% BMI 27 Sleep apnea resolved off CPAP HTN resolved No back pain Better energy 35 year-old female Height 5 7 Weight 330 lbs BMI 52 Excess BW- 185 lbs 1 year after RYGB Weight 185 lbs Wt. Loss 40 lbs %EBWL 78% BMI 29 Thank You Presented By The St. Elizabeth and St. Joseph Surgical Weight Loss Center Center of Excellence In Bariatric Surgery

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