dr alexander miras mrc clinical research fellow imperial...
TRANSCRIPT
Bariatric surgery–from morbid obesity to obese morbidity
Dr Alexander Miras
MRC Clinical Research Fellow
Imperial Weight Centre - Charing Cross Hospital
Metabolic Imaging Group - Hammersmith Hospital
What’s happening in the UK?
• No money!
• Some authorities have stopped bariatric surgery
• Others follow the NICE guidelines (BMI>35 or
40)
• Others operate only on patients with BMI>50
North West London
• We operate on patients with BMI>35 and:
• Sleep apnoea/hypopnoea
• Uncontrolled hypertension/stable CVD
• Type 2 Diabetes Mellitus
• Infertility
Case 1
• 43 year old lady
• BMI 45
• No cardiovascular/respiratory disease
• No evidence of Type 2 Diabetes
• 2 children, peri menopausal
• University lecturer
• Plays tennis twice a week
• On Thyroxine 100mcg od
Case 2
• 43 year old lady
• BMI 45
• No cardiovascular/respiratory disease
• Impaired fasting glycaemia
• Fasting glucose 6.8 mmol/l (122.4 mg/dl)
• Fasting Insulin 20 mu/l
• 2 children, regular periods
• University lecturer
• Plays tennis twice a week
• On Thyroxine 100mcg od
Case 3
• 43 year old lady
• BMI 45
• No cardiovascular/respiratory disease
• No evidence of Type 2 Diabetes
• 2 children, regular periods
• University lecturer-just quit
• Mobilises with crutches, severe knee OA
• Needs 3rd party assistance for daily life
• “My quality of life is very poor”
• On Thyroxine 100mcg od and painkillers
Case 4
• 43 year old lady
• BMI 45
• Home oxygen-cor pulmonale
• Exercise tolerance 10 meters
• Type 2 Diabetes with microvascular complications
• 2 children, regular periods
• Unemployed
• House bound
• Polypharmacy
Case 5
• 55 year old gentleman
• BMI 60
• Sleep apnoea on CPAP
• 2 cardiac stents, BP 149/96
• Type 2 Diabetes for 5 years
• HbA1c 10.6% (92.3 mmol/mol)
• Total cholesterol/HDL ratio 9.2
• University lecturer
• Walks twice a week
• On 4 agents for T2DM, Antiplatelets, statin, 4
antihypertensives, Thyroxine 100mcg od
Recent Classifications
• Before 1985: Metropolitan Life Insurance
Company height-weight tables
• 1985: NIH Consensus Conference
recommended the use of BMI
• 1997: WHO adopts BMI
• Waist Circumference and Waist-to-Hip ratio also
recommended
2.5
2.0
1.5
1.0
0 20 25 30 35 40
BMI
Mortality Ratio
Cardiovascular and Diabetes Mellitus
Moderate Very Low
Low Moderate High Very High
Reprinted from Gray. Med Clin North Am. 1989;73(1):1-13, based on statistical information from Lew et al.
J Chron Dis. 1979;32:563-576.
OBESITY AND MORTALITY RISK
Limitations
• Lack of sensitivity and specificity
• No incorporation of comorbidities
• No measure of functionality, QoL, risk
• Poor correlation with overall health
Weight Management vs Obese Morbidity
Clinic Treatment
kg Weight
management Stop
coming
Multi-
modal
Strategy
Morbid Obesity Obese Morbidity
9 domain
assessment
P1
P2
P3
Weight sensitive?
Weight resistant?
Non-weight related?
Therapy specific?
Morbidity and weight loss sensitivity or resistance
Metabolic
Ventilatory
Reproductive
CV risk
Perceived health status
ADL / QoL
Eating behaviour
Anxiety / depression
Body Image dysphoria
Economic cost
-5 -10 -15 -20 -25 -30
% weight
loss to
improve
morbidity
Aylwin 2005
Benefits of a good classification system
• Stratification of patients
• Treatment decision making
• Application of guidelines
• Audit/Research
Edmonton Obesity Staging System (EOSS)
Stage 0
Sharma AM & Kushner RF, Int J Obes 2009
Stage 1
Stage 2
Stage 3
Stage 4
co-morbidity
moderate
moderate
Obesity
EOSS Distribution Across BMI Categories
NHANES III (1988-1994)
Overweight
Class
III
Padwal R, Sharma AM et al. CMAJ 2011
50 million
23 million
10 million
6 million
EOSS Case 1
24 year-old physically active female,
BMI of 32 Kg/m2
no demonstrable risk factors, no functional
limitations, or mental health issues
Class I, Stage 0 Obesity
- Focus on prevention of further weight gain
- Health benefits of more aggressive obesity
treatment likely marginal
Sharma AM & Kushner RF, Int J Obes 2009
EOSS Case 2
32 year-old male
BMI of 36 Kg/m2
hypertension, sleep apnea, depression
Class 2, Stage 2 Obesity
- Clear benefits of obesity treatment
Sharma AM & Kushner RF, Int J Obes 2009
EOSS Case 3
63 year-old male
BMI of 54 Kg/m2
disabling osteoarthritis (wheel chair)
severe hypoventilation, fibromyalgia, generalized
anxiety disorder
Class 3, Stage 4 Obesity
- Aggressive obesity treatment unless deemed
palliative
Sharma AM & Kushner RF, Int J Obes 2009
Good points
• Incorporates comorbidities, function, QoL,
psychology
• Does not use BMI
• Management suggestions (?)
Bad points
• Relies on constantly changing definitions
• Are the conditions obesity related or not?
• Subjective parameters
• Difficult to confidently allocate patients
• Difficult to capture success of treatment
Aims
• To study the utility of King’s Criteria in assessing obese patients
A. Patient health stage scores
144 obese patients assessed before bariatric surgery
(BMI48±7)
and again 1 year after surgery (BMI 37±7)
B. Observer consistency
11 clinicians scored the same 12 patients in the 9 health
domains
(based on written information)
Methods
Basis for assigning King’s Criteria scores:
Medical history
Clinical examination
Test results
“New Patient Questionnaire”
Intra-Class
Correlations
0.62
0.93
0.66
0.78
0.86
0.54
0.76
0.51
0.28
Observers’ consistency (%)
Airways
BMI
CVD
Diabetes
Economical
Functional
Gonadal
Health status
Image of self
Aasheim E et al, Clinical Obesity 2011
Results: summary
King’s Criteria
• Captured obesity-related disease and tracked health
improvements after weight loss.
• Reasonable consistency in scoring among clinicians
Clinically useful
• Identifies which patients may gain most from treatment
• Provides baseline for later comparison
• Adds structure to MDT communication
• Shifts focus from losing weight to improving health
Limitations of King’s Criteria
• Relies on constantly changing definitions, but can be
adapted
• Are the conditions obesity related or not?
• Subjective parameters
• Potential improvements
• Refine staging definitions and weigh them
• Add more domains:
Junction of the gastro-esophagus
Kidneys
Liver
Acknowledgements
• Imperial Weight Centre • Dr Carel le Roux • Mr Torsten Olbers • Dr Florian Seyfried • Dr Ling Ling Chua • Miss Sabrina Jackson
• Institute of Clinical Sciences
• Prof Jimmy Bell • Dr Tony Goldstone • Dr Samantha Scholtz • Dr Christina Prechtl • Dr Sarah Ali • Miss Giuliana Durighel
• King’s College London • Dr Simon Aylwin
Case 6
• 43 year old lady
• BMI 45
• No cardiovascular/respiratory disease
• No evidence of Type 2 Diabetes
• 2 children, regular periods, divorced
• University lecturer-just quit
• Severe depression, house bound, regular
psychiatric follow up
• On Thyroxine 100mcg od and antidepressants
Case 7
• 70 year old lady
• BMI 45
• No cardiovascular/respiratory disease
• No evidence of Type 2 Diabetes
• 2 children, peri menopausal
• Retired University lecturer
• Plays tennis twice a week
• On Thyroxine 100mcg od
Case 8
• 43 year old Asian lady
• BMI 33.9
• 2 cardiac stents, BP 149/96
• Type 2 Diabetes for 5 years
• HbA1c 10.6% (92.3 mmol/mol)
• Total cholesterol/HDL ratio 9.2
• 2 children, regular periods
• University lecturer
• Plays tennis twice a week
• On 4 agents for T2DM, Antiplatelets, statin, 4
antihypertensives, Thyroxine 100mcg od