Bariatric Surgery in 2015

Bariatric Surgery in 2015 Peter Nau, MD, MS Assistant Professor The University of Iowa Hospitals and Clinics 1 Objectives Define the obesity epidemic The cost of obesity Discuss the complications associated with obesity Identify the options for the treatment of obesity 2 Obesity Defined What isn t obesity? It s not just a cosmetic issue It s not a something that happens just because of eating too much It s not caused by a lack of selfcontrol 3 1

Obesity Defined What is Obesity? According to the World Health Organization (W.H.O.), obesity is a chronic and progressive disease. Obesity is a result of a combination of genetic and environmental factors Obesity is an important public health issue not just for adults, but also for the children Obesity is a disease who s treatment requires an approach that is specific to each patient Obesity is progressive disease and is associated with a decreased health-related quality of life 4 Obesity Defined Definitions: According to the W.H.O., obesity and overweight are defined as abnormal or excessive fat accumulation that may impair health. Obesity: Body Mass Index (BMI) of 30 or higher. Body Mass Index (BMI): A measure of an adult s weight in relation to his or her height, specifically the adult s weight in kilograms divided by the square of his or her height in meters. An imperfect tool Does not accurately measure fat content and the proportions of lean vs. fatty tissue mass Doesn t measure visceral fat tissue and the important association between abdominal obesity and Metabolic Syndrome Doesn t account for differences in sex and race As many as 24% of Americans have unhealthy metabolic profiles despite a normal BMI 5 Obesity Defined The changing face of obesity In 1990 10 states had a prevalence of obesity less than 10% No state had prevalence equal to or greater than 15% By 2000 No state had a prevalence of obesity less than 10% 23 states had a prevalence between 20 24 No state had prevalence equal to or greater than 25% In 2010 No state had a prevalence of obesity less than 20% 36 states had a prevalence equal to or greater than 25 12 states had a prevalence equal to or greater than 30%. 6 2

BRFSS, 1985 No Data <10% 10% 14% 7 BRFSS, 1986 No Data <10% 10% 14% 8 BRFSS, 1987 No Data <10% 10% 14% 9 3

BRFSS, 1988 No Data <10% 10% 14% 10 BRFSS, 1989 No Data <10% 10% 14% 11 BRFSS, 1990 No Data <10% 10% 14% 12 4

Obesity Trends* Among U.S. Adults BRFSS, 1991 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 13 BRFSS, 1992 No Data <10% 10% 14% 15% 19% 14 BRFSS, 1993 No Data <10% 10% 14% 15% 19% 15 5

BRFSS, 1994 No Data <10% 10% 14% 15% 19% 16 BRFSS, 1995 No Data <10% 10% 14% 15% 19% 17 BRFSS, 1996 No Data <10% 10% 14% 15% 19% 18 6

BRFSS, 1997 No Data <10% 10% 14% 15% 19% 20% 19 BRFSS, 1998 No Data <10% 10% 14% 15% 19% 20% 20 BRFSS, 1999 No Data <10% 10% 14% 15% 19% 20% 21 7

BRFSS, 2000 No Data <10% 10% 14% 15% 19% 20% 22 BRFSS, 2001 No Data <10% 10% 14% 15% 19% 20% 24% 25% 23 BRFSS, 2002 No Data <10% 10% 14% 15% 19% 20% 24% 25% 24 8

BRFSS, 2003 No Data <10% 10% 14% 15% 19% 20% 24% 25% 25 BRFSS, 2004 No Data <10% 10% 14% 15% 19% 20% 24% 25% 26 BRFSS, 2005 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% 27 9

BRFSS, 2006 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% 28 BRFSS, 2007 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% 29 BRFSS, 2008 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% 30 10

BRFSS, 2009 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% 31 BRFSS, 2010 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% 32 BRFSS, 2011 WA OR ID NV UT CA AZ MT WY CO NM ME ND MN VT NH SD WI NY MA MI RI CT IA PA NE NJ IL IN OH DE WV MD KS VA MO DC KY NC TN OK AR SC AK TX LA MS AL GA FL HI 15% <20% 20% <25% 25% <30% 30% <35% 35% 33 11

BRFSS, 2012 WA OR ID NV UT CA AZ MT WY CO NM ME ND MN VT NH SD WI NY MA MI RI CT IA PA NE NJ IL IN OH DE WV MD KS VA MO DC KY NC TN OK AR SC AK TX LA MS AL GA FL HI 15% <20% 20% <25% 25% <30% 30% <35% 35% 34 BRFSS, 2013 WA OR ID NV UT CA AZ MT WY CO NM ME ND MN VT NH SD WI NY MA MI RI CT IA PA NE NJ IL IN OH DE WV MD KS VA MO DC KY NC TN OK AR SC AK TX LA MS AL GA FL HI 15% <20% 20% <25% 25% <30% 30% <35% 35% 35 Obesity Defined This is not just an adult problem Obesity rates for children has doubled in the past 30 years Over that same period, rates have tripled in adolescents This is not just a United States problem Worldwide at least 500 million adults are obese and another 1.4 billion are overweight 42 million children under the age of 5 were obese or overweight in 2013 36 12

Objectives Define the obesity epidemic (Quickly) The cost of obesity Discuss the complications associated with obesity Identify the options for the treatment of obesity 37 The Cost of Obesity Healthcare costs Since 1998, obesity is responsible for a 9.1% increase in annual medical spending As much as $147 billion was spent on the treatment of obesity in 2006, up from $74 billion in 1998 The American Heart Association indicates that weight-related medical bills account for $190 billion a year These costs are attributed almost entirely to costs generated from treating the diseases that obesity promotes The actual treatment of obesity surgical or medical are not major contributors to this amount Healthcare costs correlate with BMI BMI 30 34.9 kg/m 2 = 25% higher cost BMI 35 39.9 kg/m 2 = 50% higher cost BMI > 40.0 kg/m 2 = 100% higher costs 38 The Cost of Obesity Healthcare costs Obese people had a per capita medical spending that was $1,429 greater than spending form normal-weight individuals in 2006 Represents a 42% increase from 1998 12.9% of private payer (insurance companies) is attributed to money spending solely on obesity In the absence of obesity, Medicare and Medicaid spending would be 8.5% and 11.8% lower respectively 39 13

The Cost of Obesity Childhood Obesity is no different Direct costs from treating childhood obesity was $14.1 billion in 2008 Average annual cost for a child treated with obesity was $6,730 for Medicaid For those who were not obese, Medicaid spent $2,446 This remained true when considering private insurance with 3.4 fold increase in spending on those children with obesity The number of hospitalization with obesity as a diagnosis nearly doubled between 1999 and 2005 The costs for this increase were $237.6 million, up from $125.9 million in 1999 40 The Cost of Obesity Childhood Obesity The spending increase was consistent for outpatient expenses as well Higher outpatient visit costs Higher prescription drug costs Higher emergency room costs 41 The Cost of Obesity Obese individuals are more likely to miss work when compared to normal weight adults (absenteeism) Obesity increases the probability of missing work Overweight and obese are 32% and 61% likely to miss work respectively Morbidly obese are 118% more likely to miss work Obesity increases the number of days missed Trend of a positive association between increasing days missed and increasing BMI holds true in most professions When controlling for the presence of comorbidities such as diabetes, morbid obesity remains an independent predictor for absenteeism The cost associated with this increased absenteeism is $4.3 billion annually in the United States 42 14

The Cost of Obesity Presenteeism the phenomenon that an employee goes to work, but is feeling so ill that sick leave would have otherwise been appropriate Is associated with decreased work productivity Is thought to be a risk factor for a future decline in health There is a direct association between presenteeism in both the overweight and obese populations 43 Objectives Define the obesity epidemic The cost of obesity Discuss the complications associated with obesity Identify the options for the treatment of obesity 44 Obesity and Diabetes Type 2 diabetes occurs secondary to insulin resistance Pancreas eventually loses ability to produce insulin In 2001 almost 80% of diabetics were overweight or obese 90 95 percent of all cases are type 2 The risk of type 2 diabetes is up to 49 times higher when a person has a BMI > 35 kg/m 2 Presence and degree of insulin resistance somewhat influenced by pattern of obesity and race 45 15

Obesity and Diabetes Why does diabetes matter? Diabetes is the leading cause of kidney failure Risk for stroke and heart disease is 2 to 4 times higher in people who have diabetes Approximately 70% have mild to severe nervous system damage related to their diabetes Diabetes was the sixth leading cause of death in the United States in 2002 The risk for death among people with diabetes is approximately two times that of someone of similar age without diabetes Over 200,000 people die each year from diabetes related complications 46 Obesity and Cardiovascular Disease Heart disease is the leading cause of death for both men and women Approximately 700,000 people die from heart disease every year Obesity is an important risk factor for heart disease As the level of obesity increases, so does the risk for heart disease Increased frequency of abnormal heart rhythms in people with obesity The risk for congestive heart failure is increased with obesity Obesity puts a strain on the entire circulatory system including the brain, increasing the risk for stroke 47 Obesity and Respiratory Disease Approximately 25% of obese people have asthma Between 50 60% of people who are obese have Obstructive Sleep Apnea (OSA) OSA is associated with increased risk of dying from: Heart disease Increased blood pressure Heart failure, increased cholesterol as well as fatigue and daytime drowsiness 48 16

Obesity and Cancer In 2007, about 34,000 new cases of cancer in men and 50,500 new cases of cancer in women were due to obesity It is projected that there will be 500,000 additional cases of cancer in 2030 secondary to obesity In the United States as high as 20% of female and 14% of male cancer deaths are caused in part by obesity Translates to almost 100,000 preventable deaths per year Increased risk of colon cancer by 33% Increased risk of kidney cancer by 84% Increased risk of prostate cancer by 12% Increased risk of endometrial cancer by 152% 49 Objectives Define the obesity epidemic The cost of obesity Discuss the complications associated with obesity Identify the options for the treatment of obesity 50 The Medical Treatment of Obesity Lifestyle Approaches Dieting Low calorie (800 1500 calories/day) and very low calorie (< 800 calories/day) diets are described Low-fat, Low-carbohydrate, Low-glycemic-index, High-protein, Commercial Diets (Atkins, Weight Watchers, Zone) In the end, there is no difference in weight loss between any of the above diets Ultimately, many become discouraged and recidivism is high 51 17

The Medical Treatment of Obesity Lifestyle Approaches Physical Activity Exercising and eating the same amount of calories doesn t help the patient lose significant amounts of weight Increases in physical activity with calorie restriction results in more weight reduction Also results in more favorable changes in body composition loss of fat mass > loss of lean mass Increases in good (HDL) cholesterol, decreases in cholesterol and blood pressure are better with a combination of both diet and exercise 52 The Medical Treatment of Obesity Lifestyle Approaches Behavioral Modification Includes the idea setting goals, monitoring decisions and limiting access to behaviors that will make weight loss attempts unsuccessful May result in weight loss of up to 10% of body weight when patients work together with a support group that includes regular follow-up meetings Durability has never been shown 53 The Medical Treatment of Obesity Pharmacologic Therapy Weight loss medicines can be used in addition to the other options exercise, dieting, behavior changes to help lose weight Indications Patients with a BMI above 30 BMI above 27 with other medical problems like diabetes or heart disease When combined with lifestyle changes, weight loss is increased 3 to 5% with addition of medications Most will report gaining weight back if coming off their medications 54 18

The Medical Treatment of Obesity Pharmacologic Therapy Relatively few drugs have been FDA-approved for the medical treatment of obesity Stimulants Phentermine (Adipex-P) and diethylpropion (Tenuate) Side affects include high heart rate and blood pressure, headaches, insomnia, memory and mood changes and constipation Absorption modifiers Orlistat (Xenical, Alli) Blocks the enzyme lipase, reducing intestinal fat absorption by approximately 30% Appetite suppressant Lorcaserin (Belviq) Makes appetite go away and also makes patients feel full Side effects include headaches, dizziness, nausea and constipation 55 The Medical Treatment of Obesity The Bottom Line There is no literature to support significant weight loss with nonoperative approaches in large populations Most studies report between approximately 5% weight loss for medically assisted weight loss Anecdotally Most people can lose weight it s the durability that s an issue Many have too many comorbidities, are too discouraged, or just don t know where to start This is a complex social as well as medical problem behavior modification is often insufficient to address every issue 56 The Surgical Treatment of Obesity Who is a candidate for surgery? 1991 NIH Consensus Guidelines Anyone with a BMI of 40 or a BMI of 35 or higher with coexisting medical problems This would include, but is not limited to, high blood pressure, diabetes, sleep apnea, high cholesterol, and arthritis Now expanded to patients with a BMI > 30 and type 2 diabetes or metabolic syndrome How does it work? Two types of operations restrictive and malabsorptive Restrictive limit how much you can eat by creating a smaller stomach Includes the Adjustable Gastric Band (LAGB), Roux-en-Y Gastric Bypass (RYGB) and Sleeve Gastrectomy (LSG) Malabsorptive bypass segments of the small intestine where the absorption of nutrients occurs Includes the RYGB and LSG 57 19

The Surgical Treatment of Obesity How does it really work? Compliance Compliance with a diet program Compliance with an exercise regimen Compliance to the many demands of our program 58 UIHC Obesity Surgery The Multidisciplinary Approach Bariatric Surgeons Bariatric Nursing Co-coordinator Physician assistant Fellow & Residents Program Assistant PATIENT Administrative assistants Dietitians Physical Therapists Medical specialists Nurses 59 The Surgical Treatment of Obesity Laparoscopic Adjustable Gastric Band (LAGB) FDA approved in 2001 A strictly restrictive operation Creates a small pouch of stomach with a narrow outlet to limit food intake Marketed as a minimally invasive, reversible option to surgical treatment of obesity Outcomes BMI reduction is less than both the RYGB and LSG Less successful at treating obesity related medical problems such as diabetes, high blood pressure, high cholesterol, obstructive sleep apnea and gastroesophageal reflux disease Nearly half have the band removed and up to 60% will have a second operation 60 20

The Surgical Treatment of Obesity Laparoscopic Sleeve Gastrectomy (LSG) First performed in 2000 as a part of the larger biliopancreatic diversion Excess weight loss is approximately 60 65% at five years Treats obesity related health problems better than the LAGB, but not as well as the RYGB Weaknesses May increase symptoms of GERD Does not treat diabetes as well as the RYGB Strengths Less vitamin deficiencies Marginally decreased morbidity when compared with the RYGB 61 The Surgical Treatment of Obesity Laparoscopic Roux-en-Y Gastric Bypass (RYGB) Originally developed at the UIHC by Dr. Mason in 1967 Results in 65-70% excess weight loss at five years Weaknesses Internal hernia formation 0.5-9% risk Marginal ulcer formation 0.6-16% Increased risk for micronutrient deficiencies Strengths Excellent operation if you have GERD Best treatment option if you have diabetes Provides for best weight loss and medical problem resolution 62 Medical Treatment vs. Surgery Mortality and Surgery There is an 89% decrease in mortality at 5 years in people who had weight loss surgery There is a 90% decrease in risk of dying from diabetes and 50% from heart disease after surgery The risk of dying after the operation is approximately 3 out of 1000 patients Same as for a gallbladder removal and less than a hip replacement surgery LAGB (0.09%), LSG (0.1%) and RYGB (0.14%) The operation is safer than doing nothing at all 63 21

Medical Treatment vs. Surgery Bariatric surgery and diabetes Type 2 diabetes resolves in up to 77% and improves in over 85% after surgery Swedish Obese Subjects Study a prospective study of 4047 patients from 480 primary care centers and 25 surgical departments 2010 people in surgical group, 2037 had no surgery for a matched control group At two years after surgery, the cure rate for type 2 diabetes was significantly higher in the surgery group This was still true 10 years after having surgery Compared with conventional treatment, bariatric surgery was significantly more likely to prevent the development of type 2 diabetes STAMPEDE Trial Diabetic patients randomized to surgery or medically-assisted weight loss Improved quality of life, use of medications for lipids and blood pressure, weight loss and glycemic parameters in surgical group at three years 64 Medical Treatment vs. Surgery Bariatric surgery and cardiovascular events The number of new cardiovascular events is significantly less in those that have had surgery The number of cardiac-related deaths is also lower in those that have had surgery High blood pressure improved in almost 80% and eliminated in over 60% after surgery Bariatric surgery and cancer Surgery was associated with a significant decrease in new cancers in a female population when compared to a nonoperative cohort 65 Medical Treatment vs. Surgery Bariatric surgery and quality of life Increased health-related quality of life that is both statistically significant and durable when compared to non-operative attempts Bariatric surgery and sleep apnea Significantly improved resolution when compared to non-operative efforts. Bariatric surgery and cholesterol Hyperlipidemia improves in no less than 70% of patients after surgery Bariatric surgery and cost By 5 years, the cost of managing a patient s persistent medical issues is greater than the cost of the bariatric procedure 66 22

So which operation is for me? Important to consider the entire clinical picture Diabetes? Reflux? Multiple obesity-associated medical problems? Risk averse personality? Want the most weight loss possible no matter what? Both the sleeve and the bypass are great options Make an informed decision with which you are comfortable 67 Conclusion Obesity is an public health problem of epidemic proportions The care of the health sequelae associated with obesity imposes an incredible financial burden on the health system Medical attempts at weight loss are characterized by failures and a lack of durability The surgical treatment of obesity is the only reliable treatment for the medical problems associated with being overweight 68 Just for fun 69 23