Bariatric Surgery

Past Present Future

An Economic Perspective

Ronald Eliosoff M.D., F.R.C.P.

Prevalence of Obesity in the United States of America

1985 – 1998

Obesity Trends* Among U.S. Adults BRFSS, 1985

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

Source: Behavioral Risk Factor Surveillance System, CDC.

Obesity Trends* Among U.S. Adults BRFSS, 1986

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

Source: Behavioral Risk Factor Surveillance System, CDC.

Obesity Trends* Among U.S. Adults BRFSS, 1987

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

Source: Behavioral Risk Factor Surveillance System, CDC.

Obesity Trends* Among U.S. Adults BRFSS, 1988

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

Source: Behavioral Risk Factor Surveillance System, CDC.

No Data <10% 10%–14%

Obesity Trends* Among U.S. Adults BRFSS, 1989

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

Source: Behavioral Risk Factor Surveillance System, CDC.

Obesity Trends* Among U.S. Adults BRFSS, 1990

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

Source: Behavioral Risk Factor Surveillance System, CDC.

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%

Source: Behavioral Risk Factor Surveillance System, CDC.

Obesity Trends* Among U.S. Adults BRFSS, 1992

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Source: Behavioral Risk Factor Surveillance System, CDC.

Obesity Trends* Among U.S. Adults BRFSS, 1993

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Source: Behavioral Risk Factor Surveillance System, CDC.

Obesity Trends* Among U.S. Adults BRFSS, 1994

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Source: Behavioral Risk Factor Surveillance System, CDC.

Obesity Trends* Among U.S. Adults BRFSS, 1995

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Source: Behavioral Risk Factor Surveillance System, CDC.

Obesity Trends* Among U.S. Adults BRFSS, 1996

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Source: Behavioral Risk Factor Surveillance System, CDC.

Obesity Trends* Among U.S. Adults BRFSS, 1997

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

Source: Behavioral Risk Factor Surveillance System, CDC.

No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends* Among U.S. Adults BRFSS, 1998

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

Source: Behavioral Risk Factor Surveillance System, CDC.

No Data <10% 10%–14% 15%–19% ≥20%

UK PDS United Kingdom

Prospective Diabetes Study

ACP J Club. 1995 Jul-Aug; 123(1):5. BMJ. 1995 Apr 15; 310(6985): 1005-6.

Diabetes = $$$

The New England Journal of Medicine

Body Weight and Mortality Among Women

JoAnn E. Manson, M.D., Walter C Willett, M.D., Meir J. Stampfer, M.D.,

Graham A. Colditz, M.B., B.S., David J. Hunter, M.B., B.S., Susan E. Hankinson, Sc.D., Charles H. Hennekens, M.D.,

and Frank E. Speizer, M.D.

Volume 333 September 14, 1995 Number 11

115,000 nurses, aged 35-55 years old, from 5 Midwestern states All women, All white, All healthy, All non-smokers

1995 – 1998 Nurses Health Study

Risk of Type II Diabetes BMI ≤ 22 = 1 BMI ≥ 35 = 2

6 11 30 93.2

?

1995 – 1998 Nurses Health Study

New Diagnostic Criteria for Diabetes Mellitus

FBS 140 mg/DCL 126 mg/DCL

7.8 mmol/L 7 mmol/L

1995 – 1998

1,700,000 new diabetics in the U.S.A.

1995 – 1998

WAR ON

OBESITY

•  Fen Phen •  Meridia •  Xenical •  Metabolife •  Slim Fast •  Nutrisystem

1995 – 1998

•  Atkins •  Sugar Busters •  South Beach Diet •  Weight Watchers •  Lo Carb •  Lo Cal •  Participaction Canada

1995 – 1998

Prevalence of Obesity in the United States of America

1995 – 2010

Obesity Trends* Among U.S. Adults BRFSS, 1995

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Source: Behavioral Risk Factor Surveillance System, CDC.

Obesity Trends* Among U.S. Adults BRFSS, 1996

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Source: Behavioral Risk Factor Surveillance System, CDC.

Obesity Trends* Among U.S. Adults BRFSS, 1997

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

Source: Behavioral Risk Factor Surveillance System, CDC.

No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends* Among U.S. Adults BRFSS, 1998

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

Source: Behavioral Risk Factor Surveillance System, CDC.

No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends* Among U.S. Adults BRFSS, 1999

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% ≥20%

Source: Behavioral Risk Factor Surveillance System, CDC.

Obesity Trends* Among U.S. Adults BRFSS, 2000

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% ≥20%

Source: Behavioral Risk Factor Surveillance System, CDC.

Obesity Trends* Among U.S. Adults BRFSS, 2001

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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

Source: Behavioral Risk Factor Surveillance System, CDC.

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

Obesity Trends* Among U.S. Adults BRFSS, 2002

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

Source: Behavioral Risk Factor Surveillance System, CDC.

Obesity Trends* Among U.S. Adults BRFSS, 2003

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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

Source: Behavioral Risk Factor Surveillance System, CDC.

Obesity Trends* Among U.S. Adults BRFSS, 2004

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

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

Source: Behavioral Risk Factor Surveillance System, CDC.

Obesity Trends* Among U.S. Adults BRFSS, 2005

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: Behavioral Risk Factor Surveillance System, CDC.

Obesity Trends* Among U.S. Adults BRFSS, 2006

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: Behavioral Risk Factor Surveillance System, CDC.

Obesity Trends* Among U.S. Adults BRFSS, 2007

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: Behavioral Risk Factor Surveillance System, CDC.

Obesity Trends* Among U.S. Adults BRFSS, 2008

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: Behavioral Risk Factor Surveillance System, CDC.

Obesity Trends* Among U.S. Adults BRFSS, 2009

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

Source: Behavioral Risk Factor Surveillance System, CDC.

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Trends* Among U.S. Adults BRFSS, 2010

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: Behavioral Risk Factor Surveillance System, CDC.

WHY?

Thrifty Gene Hypothesis

-James Neel

Set Point Theory of Weight Regulation

The New England Journal of Medicine

Changes in Energy Expenditure Resulting from Altered Body Weight

Rudolph L. Leibel, M.D., Michael Rosenbaum, M.D., and Jules Hirsch, M.D.

Volume 332: 621-628 March 9 1995

Luxury Cruise Hypothesis

The New England Journal of Medicine

A Low-Carbohydrate as Compared with a Low-Fat Diet in Severe Obese

Frederick F. Samaha, M.D., Nayyar Iqbal, M.D., Prakash Seshadri, M.D.,

Kathryn L. Chicano, C.R.N.P., Denise A. Daily, R.D., Joyce McGrory, C.R.N.P., Terrence Williams, B.S., Monica Williams, B.S., Edward J. Gracely, Ph.D.,

and Linda Stern, M.D.

Volume 348: 2074-2081 May 22, 2003

Annals of Surgery Who Would Have Thought? An Operation Proves

to Be the Most Effective Therapy for Adult-Onset Diabetes Mellitus

Walter J. Pories, M.D., Melvin S. Swanson, Ph.D., Kenneth G. MacDonald, M.D.,

Stuart B. Long, B.S., Patricia G. Morris, B.S.N., Brenda M. Brown, M.R.A., Hisham A. Barakat, Ph.D., Richard A. deRamon, M.D., Gay Israel Ed.D.,

Jeanette M. Dolezal, Ph.D., and Lynis Dohm, Ph.D.

Volume 222: 339-352 September 1995 Number 3

Diets

Weight Watchers

Crestor 2 years

Bernstein Diet 2 years

The New England Journal of Medicine

Long-Term Persistence of Hormonal Adaptations to Weight Loss

Priya Sumithran, M.B., B.S., Luke A. Pendergast, Ph.D.,

Elizabeth Delbridge, Ph.D., Katrina Purcell, B.Sc., Arthur Shulkes, Sc.D., Adamandia Kriketos, Ph.D., and Joseph Proietto, M.B., B.S., Ph.D.

Volume 365: 1597-1604 October 27, 2011 Number 17

Medication Costs For 1 Month

U.S. Canada Metformin Hcl 500 mg 1 tab BID 30 days supply $27.98 $24.01 Actos 45 mg 1 tab QAM 30 days supply $310.00 $198.01 Lantus SoloStar 50 U BID 30 days supply $469.99 $231.61 Victoza 1.2 mg QAM 30 days supply $308.66 $103.03

Diovan HCT 160/25 1 tab BID 30 days supply $259.97 $104.44 Norvasc 10 mg 1 tab QAM 30 days supply $107.99 $88.40 Nexium 40 mg 1 tab BID 30 days supply $1,119.98 $504.94 Crestor 40 mg 1 tab QAM 30 days supply $155.98 $86.19 Effexor XR 150 mg 1 tab QAM 30 days supply $177.99 $82.80 Lyrica 50 mg 1 tab TID 30 days supply $253.97 $147.41 Advair Diskus 2 puffs QAM 30 days supply $465.98 $249.46

Total $3,658.49 $1,820.30

Medical Costs of Treating the Obese Diabetic

Hypertensive Patient

More hospitalizations More physician visits More lab tests Diagnosis & treatment of sleep apnea Diagnosis & treatment of cardiovascular diseases -stroke -ischemic heart disease -peripheral vascular disease Medical and surgical treatment of common orthopedic problems

Medical Costs of Treating the Obese Diabetic

Hypertensive Patient

Arthritis

Obstructive Sleep Apnea

Condition Pre-Op Post-Op

GERD 269 4

Hypercholesterol 275 8

Hypertriglyceride 158 1

Diabetes 85 1

Glucose Intolerance 50 0

Stress Incontinence 201 6

Sleep Apnea 225 5

Hypertension 118 10

Arthritis (symptomatic) 371 36

Total 1752 71

Co-morbidity Comparison in Laparoscopic Gastric Bypass

Reference: Laparoscopic Gastric, Roux En-Y – 500 Patients: Technique and Results, with 3-60 Month Follow-up, Alan C. Wittgrove, MD, FACS; G. Wesley Clark , MD., Alvarado Hospital and Medical Center, San Diego, CA. , Obesity Surgery 2000, 3:233-39

The New England Journal of Medicine

Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects

Lars Sjöström, M.D., Ph.D., Kristina Narbro, Ph.D., C. David Sjöström, M.D., Ph.D.,

Kristjan Karason, M.D., Ph.D., Bo Larsson, M.D., Ph.D., Hans Wedel, Ph.D., Ted Lystig, Ph.D., Marianne Sullivan, Ph.D., Claude Bouchard, Ph.D.,

Björn Carlsson, M.D., Ph.D., Calle Bengtsson, M.D., Ph.D., Sven Dahlgren, M.D., Ph.D., Anders Gummesson, M.D., Peter Jacobson, M.D., Ph.D.,

Jan Karlsson, Ph.D., Anna-Karin Lindroos, Ph.D., Hans Lönroth, M.D., Ph.D., Ingmar Näslund, M.D., Ph.D., Torsten Olbers, M.D., Ph.D., Kaj Stenlöf, M.D., Ph.D.,

Jarl Torgerson, M.D., Ph.D., Göran Ågren, M.D., and Lena M.S. Carlsson, M.D., Ph.D.

Volume 357: 741-752 August 23, 2007 Number 8

Annals of Surgery Surgery Decreases Long-Term Mortality,

Morbidity, and Health Care Use In Morbidly Obese Patients

Nicolas V. Christou, M.D., Ph.D., John S. Sampalis, Ph.D.,

Moishe Liberman, M.D., Didier Look, M.D., Stephane Auger, B.Sc., Alexander P.H. McLean, M.D., and Lloyd D. MacLean, M.D., Ph.D.

Volume 240: 416-423 September 2004 Number 3

The New England Journal of Medicine

Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes

Philip R. Schauer, M.D., Sangeeta R. Kashyap, M.D., Kathy Wolski, M.P.H., Stacy A. Brethauer, M.D., John P. Kirwan, Ph.D., Claire E. Pothier, M.P.H.,

Susan Thomas, R.N., Beth Abood, R.N., Steven E. Nissen, M.D., and Deepak L. Bhatt, M.D., M.P.H.

Original Article March 26, 2012 10.1056

Those who cannot learn from the past are condemned to repeat it.

-George Santayana