Obesity Management

Continuum of Care:Wellness to Bariatric Surgery

Christopher Still, DO, FACN, FACPDirector, Center for Nutrition & Weight Management

DSL#06-0486 ©2006

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Why all the Interest in Obesity Treatment?

Why all the Interest in Obesity Treatment?

• Discovery of “obesity genes”

• Management: Medical / Surgery

• Epidemic*

• Discovery of “obesity genes”

• Management: Medical / Surgery

• Epidemic*

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More Than One Half of US Adults Are Overweight or

Obese

12.8% 14.1% 14.4%

22.3%

33%

0

10

20

30

40

50

60

70

80

US

Po

pu

lati

on

Ag

e 20

+ (

%)

1960-1962NHES

1971-197NHANES I

1976-1980NHANES II

1988-1994NHANES III

2003NHANES

Overweight or Obese US Adults

BMI 25 - 29.9BMI 25 - 29.9 BMI BMI 30 30

NHLBI. Obes Res. 1998;6(suppl 2):51S-209S.Flegal, et al. Int J Obes. 1998;22:39-47.

43.3%43.3% 46.1%46.1% 46.0%46.0%

55.0%55.0%

63%63%

4

Obesity Defined by Body Mass Index (BMI)

Healthy: 20-24.9

Overweight: 25-29.9

Obese: 30-39.9

Morbid Obese: 40+

BMI = Weight (kg)/Height (m2)

Behavioral Risk Factor Surveillance System, CDC

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• Fastest-growing subset with an increased prevalence of 62% between 1994 – 2000

• Approximately 10 million Americans are morbidly obese (4.7% of the adult population)

Morbid Obesity

www.asbs.orgTrust for America’s Health Facts 2004

http://www.cdc.gov/pcd/issues/2005/jan/04_0087.htm

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2.52.5

2.02.0

1.51.5

1.01.0

002020 2525 3030 3535 4040

BMIBMI

Mor

talit

y R

atio

Mor

talit

y R

atio

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ModerateRisk

VeryLow Risk

Low Risk

ModerateRisk

High Risk

VeryHigh Risk

MenMenWomenWomen

Digestive andpulmonary disease

Cardiovascular andgallbladder diseaseDiabetes mellitus

Obesity and Mortality Risk, 1989

Obesity and Mortality Risk, 1989

1 Adapted with permission from Gray DS. MedClin North Am. 1989;73:1

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• Abnormal PFTsPulmonary disease

• Obstructive sleep apnea• Hypoventilation syndrome

Gall bladder disease

• PCOS

Gout

Stroke

• DiabetesCardiovascular disease

• Hyperlipidemia• Hypertension

• Insulin resistance syndrome

• Breast, uterus, cervixCancer

• Colon• Prostate

• SteatosisLiver disease

• NASH• Cirrhosis

Phlebitis

Medical Co-Morbidities

Osteoarthritis

PCOS = polycystic ovarian syndrome

NASH = nonalcoholic steatohepatitis

NIH/NHLBI. September 1998; NIH publication no. 984083.

Gynecologic/Urologic abnormalities• Abnormal menses• Infertility

• Stress incontinence

Premature Death

Depression

GERD

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“Right behind this obesity epidemic is a diabetes epidemic,

and that’s very expensive.”

• 9 out of 10 people newly diagnosed with Type 2 Diabetes are overweight

• Direct medical expenditures incurred by individuals with diabetes $13,243 vs. $2,560 for person without diabetes

Wolf AM, Colditz GA. Current estimates of the economic cost of obesity in the US. Obesity Research. 1998 6(2):97-106. Pories WJ, et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus.

Annals of Surgery. 1995; 222(3):339-352. http://www.diabetes.org/DiabetesCare/1998-02/pg296.htm

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The Cost of Obesity Compared to other Chronic Diseases

$ Billions

Obesity 1 75.0Type 2 Diabetes 2 73.7Coronary heart disease 352.4Hypertension 4 28.2Arthritis 5 23.9Breast Cancer 6 7.1

1 Finkelstein EA, Obes Res 2004;12 4. Hodgson TA et al. Med Care 2001;39:599 2 ADA Diabetes Care, 2003;26:917 5 Yelin & Callahan. Arthritis Rheum 1995;38:13513 Hodgeson TA et al. Medical Care 1999:37:994. 6Brown ML, et al. Medical Care; 2002;40(suppl): IV-104

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“Obesity harder on health than smoking.” Reuters Health 03/13/2002

• Obesity raises individual:

– Healthcare costs by 36%

– Medication costs by 77%

RAND/UCLA study

• Smoking raises individual:

– Healthcare costs by 21%

– Medication costs by 28%

Sturm, Roland. The effects of obesity, smoking and drinking on

medical problems and costs. Health Affairs 21(2): 245-253

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Economic Cost of Obesity: Employer costs

Total cost to US employers estimated at $13 billion/year:• $8 billion in health insurance• $2.4 billion in paid sick leave• $1.8 billion in life insurance• $1 billion in disability insurancePrevention Makes Common Cents: Estimated Economic Costs of Obesity to U.S. Business, DHHS,2003

Associated annually with:

• 39 million lost work days• 239 million restricted-activity days• 63 million physician visits• 89 million bed-daysNBGH (Institute on the Costs and Health Effects of Obesity)

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Thompson, D.et al. Am J Health Promot 1998;12:120-127

Percent Unable to Work9.6

5.65.9

12.6

7.9

4.7

Healthy Weight Overweight Obese

Men Women

Obesity: Greater Rates of Disability

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Consequences of ObesityAre Devastating

risk of morbidity and mortality1,2

Risk factors

health costs to– Patient– Healthcare system

workforce productivity3

absentee rates employer costs (5%)

1Pi-Sunyer FX. Am J Clin Nutr. 1991;53(suppl 1):1595S.2Calle EE et al. N Engl J Med. 1999;341:1097.

3Thompson D et al. American Journal of Health Promotion. 1998;13:120.

WellnessWeight/Medical Management

Bariatric Surgery

How Is Obesity Treated?

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Components of an Effective Obesity Management

Program

Wadden TA, Foster GD. Behavioral treatment of obesity. Med Clin North Am. 2000;84:441-461

Stumbo, PH, et. al. Dietary and medical therapy of obesity. Surg Clin N Am 85(2005)703-723

Diet

PhysicalActivity

BehaviorModification

Medicationsor

Surgery

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• Standardized meal plans instructed by RDs– 1200 – 1500 Kcal, 25% - 30% fat– 1500 – 1800 Kcal, 25% - 30% fat– ADA (food exchanges) diabetes, PCO, etc.

• Daily food logs journal• Weekly weigh-in• “Occurrence” exercise program• Water intake• Behavior modification lessons• Pharmacotherapy if weight loss plateaus• Bariatric surgery after comprehensive process

Medical ManagementTreatment Plan

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Diet and Physical Activity

Pavlou KN, et al. Am J Clin Nutr. 1989;49:115-1123

ExerciseNonexercise

Balanced caloric deficit dietProtein-sparing modified fast

0-0-

2-2-

4-4-

6-6-

8-8-

10-10-

12-12-

14-14-

16-16-

1 2 3 4 5 6 7 8 9 10 11 121 2 3 4 5 6 7 8 9 10 11 12 3030

Treatment (wk) Follow-up (mo)

Weig

ht

loss

/gain

(kg

)

18

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Weight Loss Medications

sibutramineMeridia1

orlistatXenical2

phentermine Adipex3

Average Weight Loss at

1 yr

4.5 kg (9.9#) 2.59 kg (5.7#) 3.6 kg (7.92#)

Concerns monitor b/p GI symptoms monitor b/p

Epocrates Rx Online. San Mateo (CA): Epocrates, Inc. 2003-(cited 2006 Jan 23). http://www2.epocrates.comZhaoping Li, MD, PhD, et. al. Meta-analysis: Pharmacologic Treatment of Obesity. Ann Intern Med. 2005;142:532-546.

1Knoll Pharmaceutical Company. 2 Roche Group. 3 Phentermine (generic)

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Success Rate of Various Weight Loss Treatments

• Conventional (obese)

Diet

ExerciseBehavior ModificationAnti-Obesity Drugs

• Surgical Therapy (MO)

Weight Loss Surgery

95% to 98% failure rates of sustained weight loss in obese population at 5 yrs

99% failure of sustained weight loss for the morbidly obese population

50% success rate at 16 years

http://www.nhlbi.nih.gov/guidelines/obesity/practgde.htm accessed 5 February 2006 Rosenbaum M, Leibel RL. Obesity: Medical Progress. NEJM 1997; 337:396-407.

Buchwald, H et. al. Bariatric Surgery A Systematic Review and Meta-analysis. JAMA 2004; 292:1724-1737

Bariatric (Obesity) Surgery

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Why Surgery?

• Works when all other therapies fail• Resolves co-morbidities• Standardization of procedures• Risk: surgery < maintain morbidly

obese

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0.68%

6.17%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

BARIATRIC* CONTROLS

MO

RT

AL

ITY

* Includes peri-operative (30-day) mortality of 0.4%p-value 0.001Christou (McGill University, Montreal, Canada)

Implication of not managing morbid obesity

89% REDUCTION IN RISK OF DEATH OVER 5 YEARS

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Treatment for Morbid Obesity

• Surgery is only a TOOL

• A TOTAL PROGRAM facilitates success– Pre-Surgical & Post-Surgical counseling– Nutritional counseling– Exercise & Weight Management Programs– Psychological evaluations & counseling– Support groups– Patient for Life

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Multidisciplinary Team Approach

Bariatric Surgeons Physician / Bariatrician Case Manager Nurse Specialist Registered Dietitians Exercise Physiologist/ Physical

Therapist Behavioral Psychologist Research coordinator and technician Insurance Coordinator

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Overview of Bariatric Surgery Process

• Stop smoking 60 days prior to surgery• 10% weight loss from initial presentation• Read book & complete 10 behavior

modification modules• Attend 2 educational groups sessions• Attend 2 patient support groups• Metabolism / body composition

determination• Psychiatric evaluation• Medical evaluation• Surgical evaluation

(at least 6 months)

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Who Is a Surgical Candidate?

• Meets current criteria• Failed medically supervised weight loss

attempts• Age limits vary by program• No endocrine cause of obesity• Acceptable operative risk• Understands surgery & risks • Absence of active drug or alcohol issues • No uncontrolled psychological conditions• Consensus by multi-disciplinary team• Dedicated to life-style change & follow-up

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Indications for Bariatric Surgery

CMS (2006)

– BMI > 35 w/co-morbid condition– Documented ineffective weight loss

attempts– Center of Excellence– Specific procedures: RNY (open & lap),

LAGB®, BPD, BPD/DS; excludes VBG– Surgery- for treatment of co-morbidities and

medical complications related to obesity

Decision Memo for Bariatric Surgery for the Treatment of MO (CAG0025OR)

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Centers of Excellence  

Resources to perform safe bariatric surgery

• Equipment, Supplies & Training of Surgeons• Multi-Disciplinary Team

Excellent short & long term outcomes• Objective Data Outcome• Clinical Pathway & Process

http://surgicalreview.org/

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Post Operative Bariatric Care:Routine Follow up Visits

• Match appointment w. surgeon, internist & RD• Adjust medications & vitamins• Advance Diet• Access fluid & protein intake• Physical function testing • Complete QOL, BDI, Mood surveys• Repeat metabolism / body comp determination• Follow up biometrics as indicated

(1 week; 1 month; 2 months; every 6 months; every year)

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Communication between Program -

PCP, Health Plan & Employer

is Imperativefor Long-term Success

Plan for SurgeryPlan for Postoperative CarePlan for Long-term follow up

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Improvement of Co-Morbid Conditions

•86% of diabetes resolved or improved•70% of hyperlipidemia improved•78.5% of hypertension resolved improved•83.6% of sleep apnea resolved or

improved•400% Reduced incidence of cancer

(2.03% vs. 8.49%)

Buchwald H, Avidor Y, Braunwald E, et al. Bariatric Surgery – A Systematic Review of the Literature and Meta-analysis. Journal of the American Medical Association, October 13, 2004 – Vol. 292, No. 14

136 studies representing all together 22,094 patients

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Reduction in Medication Costs…

0

50

100

150

200

250

Total DM HTN

Pre

scri

pti

on

Med

icat

ion

Co

st

Pre-RYGBP Post-RGBP

Monthly Prescription Medication Costs before and after RYGBP

Potteiger CE, et al. Obesity Surgery, 2004:14:725-730

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Weight Loss Surgery Results in:

• 89% Decreased Risk of Death(including 0.4% operative mortality)

• 67% long-term loss of excess body weight

• 45% Reduction in total health care costs (including cost of surgical procedure)

• 50% Reduced hospital days

Christou (McGill University, Montreal, Canada)

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0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

Gall Bladder Gastric Bypass Heart Surgery

Mortality (in Percentage)

Mortality Rates in Context

1. Bariatric Mortality - Buchwald H, Avidor Y, Braunwald E, et al. Bariatric Surgery – A Systematic Review of the Literature and Meta-analysis. Journal of the American Medical Association, October 13, 2004 – Vol. 292, No. 14.

CABG Mortality – Angelin, Lancet 2002.

Cholecystectomy Mortality – Muller BP, Holzinger F, Leeping H, Klaiber C. Laparoscopic Cholecystectomy: Quality of Care and Benchmarking. Surgical Endoscopy 2003, Vol. 17, No. 2, pp. 300-305.

2.0%

.5%.2%

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19961991

Obesity Trends* Among U.S. AdultsBRFSS, 1991, 1996, 2004

(*BMI 30, or about 30 lbs overweight for 5’4” person)

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

2004

Behavioral Risk Factor Surveillance System, CDC. F as in Fat: How Obesity Polices are Failing in America: 2005

Ranks 22nd

23% obese6% diabetic

Ranks last16.8% obese4.3% diabetic

Ranks #129.5% obese9.6% diabetic

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Conclusion

The magnitude of the problem (obesity) is great

A comprehensive approach (diet, exercise, behavior modification) is the best approach for success

Continuum of Care (wellness, weight management & bariatric surgery) will insure a healthier population

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Conclusion

Surgically induced weight-loss in Morbid Obesity

Decreases mortality risk

Decreases the risk of developing new health-related conditions

Reduces health care utilization and direct health care costs

Co-morbidities are resolved, alleviating additional treatment & pharmaceutical costs

The Impact of Weight Reduction Surgery on Health-Care Costs in Morbidly Obese Patients; Obesity Surgery, 14, 939-947; John S. Sampalis, PhD; Moiseh Liberman,MD, Stephane Auger, BSc, Nicolas V.

Christou, MD PhD

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 ConclusionSuccessful Treatment of the MO

patientcollaborative effort

Bariatric Team (Surgeon, Bariatrician, RD, Mental Health Counselor)

Primary Care PhysicianHealth Plan (case manager)Employer

All disciplines must work together to ensure an optimal outcome with long-term results

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Resources

Websites:

– http://www.geisinger.org/consumers/services/gastro_nutr/

– http://www.asbs.org/– http://www.weightlosssurgeryinfo.com

/– http://www.fitday.com/– http://www2.epocrates.com/index.htm

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