Weight LossInformation Session

Agenda

• Understanding Obesity• Are you a Candidate? • Weight Loss Surgery Options • The Process• Next Steps

Understanding Obesity

• Clinically severe obesity at which point serious medical conditions occur as a direct result of the obesity

• Defined as >200% of ideal weight, >100 lbs overweight, or a body mass index of 40

• BMI = weight (kg)_____ height (m) x height (m)

What is Morbid Obesity

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WeightWeight (lbs)(lbs)

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5'05'0""

5'105'10""

5'85'8""

5'65'6""

6'06'0""

6'26'2""

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What is your BMI?

Clinical Terms Used to Describe Various Levels of Body Fat1

Normal Weight (BMI* 18.5 to 24.9)

Overweight(BMI 25 to 29.9)

Obese(Class I)

(BMI 30 to 34.9)

Obese(Class II)

(BMI 35 to 39.9 )

Extremely Obese(Class III)

(BMI 40 or more)

1. National Institutes of Health/National Heart, Lung and Blood Institute Clinical Guidelines Evidence Report. NIH Publication 98-4083, September 1998.

Degrees of Obesity

• Co-morbid diseases (medical and non-medical)– diabetes, hypertension, cancer, sleep apnea, depression

• Decreased quality of life– Psychological: low self-esteem, depression– Social: workplace, friends, home, associates

• Increased medical costs• Disability• Increased risk of premature death

Impact of Obesity

• Diabetes

• Hypertension

• Sleep apnea

• Depression

• Joint pain

• Infertility

• Cancer

• GERD

• Asthma

Calle EE, Michael MJ, Petrelli JM, et al. Body-mass index and mortality in a prospective cohort of US adults. N Eng J Med. 1999;341(15):1097-105.

Health Risks

BMIGray DS. Med Clin North Am. 1989;73(1):1–13.

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2.0

1.5

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MortalityRatio

Moderate VeryLow Low Moderate HighHigh Very

High

Obesity and Mortality Risk

Are you a Candidate?

• BMI >40 or >35 with two co-morbidities• Absence of current drug or alcohol abuse problems• Absence of anorexia, bulimia• At least 18 years old• Multiple weight loss attempts• Consensus after bariatric team evaluation

– psychologist, internist, dietitian

• Are prepared to attend regular follow-up sessions and make lifestyle changes

Candidate for Surgery

Why and Who

• Surgery is the only approach that provides consistent, permanent weight loss for morbidly obese patients.

• Surgery indicated in patients with:– BMI of 40 or over– BMI of 35-40 with a significant co-morbidity– Documented diet attempts ineffective

Source: National Institute of Health Consensus Conference; 1991

Why Surgery?

• Diet and exercise only works for 1 in 20 people who are morbidly obese

• Surgery is safe and effective• Improves co-morbidities• Benefits of surgery outweigh the risks for the

morbidly obese

The “Other Side”

• Surgery is a serious event • Surgery is not the “easy way out”

– Requires multiple pre-op visits and tests– Insurance hassles and/or personal expense– Adjustment to drastic life change– Life-long maintenance and follow-up

Patient Stories - Before: (INSERT HERE)

• Deborah Patient

Weight Loss Surgery Options

Advantages of Laparoscopy

• Fewer wound complications • Less infection• Fewer hernias• Less pain and faster recovery• Surgeon has better view of the anatomy

Nguyen 2001, Wittgrove 2000, Schauer 2000, Watson 1997

• Several small incisions made in the abdomen

• Telescope and small instruments placed in abdomen

• Improved recovery over open incision• Open surgery required in some situations

Laparoscopic Surgery

Surgical Options

• Restrictive procedures reduce how much the stomach can hold– Adjustable Gastric Band– Sleeve Gastrectomy

• Combined procedures of restriction and malabsorption shorten the digestive tract and reduce how much the stomach can hold– Gastric Bypass

Adjustable Gastric Band

• A silicone band is placed around the upper part of the stomach.

• It is filled with a saline solution. • By adding or removing the

saline, the band can be made tighter or looser.

• Adjustments are made to meet individual weight loss needs:– A small pouch is created– Your stomach holds less food– You feel full faster and longer

Advantages• Least invasive approach• No stomach stapling or cutting,

or intestinal rerouting• Adjustable• Reversible• Lowest operative complication

rate• Lowest mortality rate• Low malnutrition risk

Disadvantages• Slower initial weight loss than

gastric bypass• Regular follow-up critical for

optimal results

Adjustable Gastric Band

Sleeve Gastrectomy

• Restrictive procedure• Large portion of stomach removed

to leave a pouch that holds about 200mls

• No disconnection from intestine as in gastric bypass

• Less invasive/risk as a result

Advantages• No malabsorption• No adjustments• Fundus removed• Can be converted to a gastric

bypass later if needed

Disadvantages• Stomach may stretch over time• Large portion of the stomach

removed• No long term data

Sleeve Gastrectomy

Gastric Bypass

• Stomach separated into two parts using staples

• This creates a small pouch that will hold two to three ounces of food

• Sufficient intestine still remains for proper digestion

• Eaten food now bypasses the lower stomach and about 100cm of intestine

• Now you can only eat small amounts of food and the food goes undigested for part of the way

Bypass Dumping Syndrome

• Due to high osmolarity of simple carbs in proximal intestine

• Causes fluid shift that leads to cramping

• Sweating, palpitations, nausea, vomiting, etc.

• A “benefit” of gastric bypass

Sources: 1. Kral, J.G.  Surgical Treatment of Obesity. Handbook of Obesity, ed. Bray, G.A., Bouchard, C., James, W.P.T.  New York. Marcel Dekker, Inc., 1998. 2. Gastriointestinal Surgery for Severe Obesity. National Institutes of Health. National Institute of Diabetes and Digestive and Kidney Diseases. December 2004, NIH Publication No. 04-4006.

Advantages• Rapid initial weight loss• Minimally invasive approach

is possible• Longer experience in USA• Higher total average weight

loss reported than with LAP-BAND System or VBG

Disadvantages• Cutting and stapling of

stomach and bowel is required

• More operative complications than with LAP-BAND System/LSG

• Portion of digestive track is bypassed, reducing absorption of essential nutrients

Gastric Bypass

Results of Weight Loss Surgery

• Weight Loss• Cure or Improvement in Co-morbidities• Increased Longevity• Improved Quality of Life

– Health– Social– Personal– Work

Weight Loss Results

< 50> 35Failure

50–7530–35Good

> 75< 30Excellent

% Loss of EBW BMI (kg/m2)Result

Successful Weight Loss Surgery

Type 2 Diabetes 95%

GERD 98%

Stress Incontinence 87%

Sleep Apnea 75%

Arthritis 82%

Hypertension 92%Hypercholesterolemia 97%

Wittgrove AC,Clark GW. Laparoscopic Gastric bypass roux-n-y-500 patients. Obes Surg 2000. And others.

What to expect after surgery

• In addition to losing weight, you can expect:– Be rid of medications for diabetes, oxygen for sleep apnea, improved

arthritis, better cholesterol levels– Socialize more– Feel better about yourself – no more discrimination– Enjoy new relationships or explore new aspects of current relationships – Exercise, sports

Patient Stories - After: (INSERT HERE)

• Deborah Patient

The Process

Insurance

• Most plans require documented failure of conservative treatments and high patient motivation before approving surgery.

• A growing number of states have passed legislation that requires insurance companies to provide benefits for weight loss surgery for patients who meet the National Institutes of Health surgical criteria.

• Insurance coverage often requires a lengthy and complicated approval process.

Suggestions to help avoid insurance problems:• Confirm with your employer (human resources) if

bariatric surgery is covered.– Just because it is medically necessary does not mean it is

covered by the particular plan your employer decided to purchase.

– Document diet attempts in your physician’s office.– Ensure your surgeon receives all of your dietary history and

workup results.• We will send a letter, your results and journal articles showing

benefits of bariatric surgery from a health and financial standpoint.

Insurance

• Attend information session • Initial consult with surgeon• Evaluation and clearance process • Final surgical consult pre-surgery• Begin two-week liquid diet• Surgery• Post-surgical follow-ups with surgeon and

primary care physicians

Weight Loss Surgery Process

Common Pre-surgical Consults/Tests

• Psychological consult and clearance

• Dietitian consults• Fitness consult• Sleep study• Chest X-ray

• Abdominal ultrasound• Stress test• Upper endoscopy

Next Steps

Surgery Follow-up Actions

• Subscribe to Nutrition/Diet Plan• Regular Exercise as Advised by Physician• Undergo Behavior Counseling/Therapy• Regular Follow-ups with Physician

• You have just completed Step 1 of the process.• Request an appointment today on your evaluation

form or call to schedule an appointment.• If you are not ready today…go home and think about:

– How serious you are about weight loss– How committed you are to changing your lifestyle and

habits– Which surgery is right for you

• Talk to others and visit the Web to research more.

Next Steps

Thank YouQ & A