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Christopher Still, DO - Geisinger Health System
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Christopher Still, DO - Geisinger Health System

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  • It is projected that by 2008, 73% of us will be overweight or obese. It took us over 40 years to go up 20%, now we’re going up 10% in 5 years! This illustrates the increase in obesity in the last few decades. Number of Obese American adults rose to 24.5% Over last decade alone an increase of 12% - overweight 70% - obese Occurred for all population subsets: children, elderly & all racial/ethnic groups According to projections, 73 percent of American adults could be overweight (34 %) or obese (39 %) by 2008* BMI ≥ 40 - quadrupled in 17 years 1983 - @1.2 million to 2000 - @5.64 million (Roland Sturm, PhD, Arch Intern Med.  2003;163:2146-2148 ) Media reports, official pronouncements, a national summit and, now, this report, America's Health: State Health Rankings, all have focused our nation's attention on obesity and overweight as a fast-growing, major threat to people's health. Physical inactivity and poor nutrition - risk factors that contribute to obesity and overweight – together are the second leading cause of premature death, behind only tobacco. These risk factors contribute to arthritis, asthma, cancer, diabetes, heart disease, stroke and other deadly and debilitating diseases. They cost our nation dearly in the following ways: The direct and indirect costs of obesity in the United States total $117 billion. Obesity costs our economy more than 39 million lost work days each year. Three-fourths of the $1.4 trillion the United States spends on health care is to treat chronic illnesses, many of which are tied to obesity and overweight.
  • BMI is another way of looking at how healthy your weight is in relation to your height. It does not take into account muscle mass. Evaluates weight relative to height, doesn’t account for muscle mass Replaces ideal body weight Correlates highly with body fat, morbidity, and mortality.
  • It is chronic and can be fatal.
  • As the BMI goes up, the mortality risk goes up.
  • Obesity affects every body system, increasing the risk for potentially disabling co-morbidities. Percentages of Co-Morbid Medical Conditions Associated with Morbid Obesity Diabetes 9-50% Hypertension 13-81% Hyperlipidemia 60-68% Cardiac Disease 6-55% Sleep Apnea 6-50% Osteoarthritis 23-83% Heart Burn (GERD) 27-81% Depression 70-90% Stress Incontinence 15-83% Menstrual Irregularity 12-21%
  • The nation spends $13,243 on each person with diabetes, compared to $2,560 per person for people who don't have diabetes . If you own a company with 500 employees and you know you are going to spend 5 times as much on a non-diabetic as a non-diabetic employee, who are you going to want working for you? You treat the obesity, you treat the diabetes.
  • Obesity tops this list and is an underlying factor for the other five chronic diseases listed. If you treat the obesity, you are treating the co-morbid conditions.
  • CHRIS **Focus on behavior – not think twice pay for lung ca – smoking but obesity no coverage While smoking is a behavioral issue and obesity is often VIEWED as a behavioral issue, you can’t legislate common sense, however, you can educate your patients, assess their needs, plan an appropriate treatment plan, facilitate appropriate referrals, and advocate for the best possible long-term outcome.
  • ***Direct & Indirect Costs of Obesity: $117billion each year, according to estimates from the US Department of HHS. Obese employees take more sick leave than non-obese employees and are twice as likely to have high-level absenteeism –seven or more absences due to illness during a six month period (F is for fat: Trust for America’s Health 2005) $61 billion in direct medical costs for trmt of related diseases $56 billion in indirect costs such as lost productivity.
  • People who are overweight and obese miss more work compared to people with a healthy body weight. This trend is more evident among women. In a company with 500 employees, this excess loss productivity among overweight and obese workers would amount to a loss of approximately 311 days per year. Overall, in the United States in 1994, obese employees missed approximately 39 million more days of work than employees with a healthy body weight (BMI > 30 kg/m2). Collectively, that cost employers 39 billion dollars ( in 1995 dollars). Study Specifics: The data is from the 1993 National Health Interview Survey as analyzed by Thompson et al in the paper referenced below. The BMI cut points for overweight are 25-28.9 kg/m2 and for obesity: BMI > 30 kg/m2, hence they are slightly different than the NHLBI and WHO definition of overweight and obesity. This slide was adapted from Table 5 where age groups were averaged to derive the figure’s data. Days missed for a company with 500 employees was derived by taking gender specific prevalence of overweight (25-28.9 kg/m2) and obesity (BMI > 29 kg/m2) in the NHIS (listed below) working population. The number of overweight men and women was then multiplied by the excess (the difference between the overweight or obese and the healthy weight groups) number of work loss days. See below: National data was taken from Wolf, AM (ref below) and was from the 1994 NHIS. BMI cut points were in agreement in the WHO and NIH definition for obesity. NHIS Prevalence of Overweight and obesity in working population in 1993—Table 1 of Thompson D et al. Overweight Obese Men 38.4 30.1 Women 22.2 24.6 This has been observed in Sweden as well. Sweden 1 Obese women have 1.5-1.9 times more sick leave than non-obese women.
  • The harmful consequences of obesity are multifactorial and are felt across all demographic groups The consequences are profound and wide reaching. All feel the adverse effects Men and women Young and old All ethnic groups, races, and cultural groups All occupations and workplaces The consequences of obesity are serious and include Increased morbidity and mortality Reduced productivity and functioning Increased healthcare costs (costs increase at older ages, and prevention of obesity at early ages could dramatically reduce these costs) Social and economic discrimination (underachievement in education, reduced social activity, job discrimination) Slide
  • PAM Keep in mind the following scenario as we discuss treatment options: Single mother of two, divorced, works two jobs, doesn’t have time to exercise, doesn’t have time to cook the traditional healthy meal, views fast food as the cheap, easy way to feed her family. T2DM, HTN, Hypercholesterolemia, OSA, OA Glucophage, Lotensin, Lipitor, CPAP, Voltarin
  • The cornerstone of treatment is to first address the diet-number of calories, source of calories, % prot/cho/fat/fiber, etc. Referral to a RD!!! Increased physical activity HAS to be a component of the program. Consider referral to PT or an exercise physiologist to determine their activity tolerance and to receive an exercise prescription that includes three stages: initiating the exercise or activity, achieving the optimal level of expenditure for weight reduction, and stressing the on-going effort required for weight maintenance and preventing weight gain. [i] Stumbo, PH, et. al. Dietary and medical therapy of obesity. Surg Clin N Am 85(2005)703-723 While assisting the patient to set their weight loss and exercise goals, discuss, identify and address barriers. Behavioral therapy helps patients develop the skills they need to identify and modify eating and activity behaviors, and change thinking patterns that undermine weight control efforts. [i] Wadden TA, Foster GD. Behavioral treatment of obesity. Med Clin North Am. 2000;84:441-461. After addressing diet, exercise and behavior modification, the use of weight loss medications or weight loss surgery needs to be considered. We’ll talk in more detail about meds & surgery later.
  • PCP
  • This slide reinforces the fact that diet alone is not as effective as diet combined with an exercise program. “THE AVERAGE AMERICAN NOW DRIVES 73 MINUTES PER DAY AND USES THE AUTOMOBILE FOR ALMOST 90 PERCENT OF TRIPS REGARDLESS OF DISTANCE. CHILDREN BETWEEN THE AGES OF FIVE AND FIFTEEN...WALKED AND BIKED 40 PERCENT LESS IN 1995 THAN IN 1977.” — “Relationship Between Urban Sprawl and Physical Activity, Obesity, and Morbidity”173
  • Sibutramine: Induces feeling of satiety, caution with use in combination with SSRI’s, need to monitor BP Orlistat: Reduces absorption of ~30% dietary fat, 1/3 of fat passes undigested which can result in not so pleasant GI effects 3 times daily with meals containing fat Phentermine: has been around the longest, was one ½ of phen-fen Rimonobant: new medication that works on the endocannabinoid receptors in the brain, FDA approval is pending
  • CHRIS Diet and exercise are not effective long term in the morbidly obese. Surgery is the only proven method for long-term weight control in morbidly obese patients, when all other therapies have failed. It resolves co-morbidities. There are standardized procedures with well-recognized and documented results. Weigh benefits of surgery vs. the risks of staying morbidly obese . Recent study showed that mortality for surgical patients was 0.68 percent, compared to non-surgical patients with 6.17 percent.
  • PAM Failed medical weight loss attempt Attend informational seminar Attend support group Comprehensive psychological evaluation Nutritional Education Medical Evaluation Stop Smoking prior to surgery ? Weight loss prior to surgery
  • A successful program is made up of….. Importance of a Dedicated Physician on the Team Medical / Nutritional Management “Relapse” prevention Laboratory tests-pre and post Documentation of weight loss attempts Referrals: RD, PT, MH Counselor Continuum of Care: Weight Management, Surgery, Wellness Coordinates care with Payor Case Manager Provides: Education, Communication and Follow-up
  • Consensus Statement (1991) evaluated the state of bariatric surgery Patients should be managed medically before surgery Gastric restrictive or bypass procedures are appropriate for motivated patients Multi-disciplinary team approach Life-long medical surveillance Surgery is the only approach that provides consistent, permanent weight loss for morbidly obese patients Specific procedures VBG & RNY, prior to FDA approval for LAGB ® National Coverage Determination (NCD) (opened May, 2005; decision Feb., 2006) Medicare and Medicaid pay over half of the nation’s bill to treat obesity-related conditions– $39 billion out of a total of $75 billion in direct medical costs each year. Bariatric surgery, is used for the treatment of co-morbidities and medical complications related to obesity and, therefore, is not considered cosmetic surgery. To appraise the benefits of bariatric surgery for co-morbid conditions related to obesity in comparison with non-surgical medical management, CMS chose the following outcomes: sustained weight loss; short- and long-term mortality; complications of surgery (also using length of stay as a marker); and effect on co-morbidities. Medical treatment for obesity includes dietary manipulation, behavior modification and medication. These therapies have been tried individually and in combination, but with only limited long-term success. However, based on the lower risk-benefit ratio for medical treatment, we believe it should be routinely attempted and shown to be unsuccessful before considering a patient for bariatric surgery. There are no consistent standards in the literature regarding length of a medical treatment trial and, therefore, we are unable to specify a specific time interval. A number of trials and guidelines recommend 6 to 12 months and we believe that to be reasonable. In our review we found, in the general population, that post-surgical sustained weight loss may be an attainable goal with combination or malabsorptive procedures showing greater weight loss than restrictive procedures, which, in turn, demonstrate significantly more weight loss than no surgery. The NCD requestors recommended that bariatric surgery procedures be covered for beneficiaries with a BMI > 35% with at least one co-morbidity or with a BMI > 40% without any co-morbidity. Generally, a common comment introduced pertained to the subjective nature of the medical treatment requirement prior to surgery. Some stated that there were no data to support such a requirement and others stated that the requirement only prolonged the time to needed surgery. The standard of care for any surgical procedure is that medical management options are exhaustively considered and exercised by both patient and physician prior to surgery. This standard applies to the treatment of co-morbid conditions related to obesity. We will not impose a specific time period, but expect all surgeons to be part of a comprehensive program for the treatment of co-morbid conditions related to obesity and to have applied principles of good medical care prior to surgery.
  • PAM Partner with established centers with good outcomes (COE) Communicate! with the patient, the PCP, the Case Manager/Program Coordinator and Surgeon Assist the patient through the process Reinforce the rationale for why the steps are necessary To ensure the best long term outcome Not “just because it’s required” Encourage preoperative (& postoperative) support group attendance Evaluate the patient’s readiness to change (Prochaska’s stages of change) Stress the importance of: The Psychiatric evaluation and possible therapy Dietary compliance *ask for a copy of all the materials the patient receives from the facility and keep a resource notebook for the different programs Keeping follow up appointments with Surgeon & PCP Weaning medication Monitoring labs Continued dietary compliance Support group attendance *know their schedule of support groups and f/u appts* Partner with payers & employer Communicate! with the patient, the PCP, Insurance/Payer Case Manager, the Employer representative (nurse, CMgr, etc.) Provide current obesity/MO treatment, news, literature Provide education on program, new treatments, etc. Educate the patient & family pre-op. and post-op. Appropriate procedure for the appropriate patient Approval process Estimated time off from work What is their home environment/support system Likelihood to need HH/DME Update the Insurance/Payer Case Manager during the hospital stay and after each office visit Follow up with PCP & Specialists re: resolution of co-morbids, lab results Follow up calls (to patient) with each diet advancement Monthly “check in” calls during the first year
  • CHRIS *PCP for life – needs to know when appropriate to treat or when it is time to send to surgeon surgery to ensure the patient’s co-morbidities Prior to surgery, the PCP needs to know what the plan will be after surgery, how frequent will f/u appts. be, when/what labs will be drawn, what are the dietary requirements, what vitamin supplements are necessary. They need to know that the patient will be followed long-term by the bariatric surgery program, with continued communication/updates after those visits-is their weight loss on track? If not, why not? Have they required changes to their vitamin supplements based on lab results? Has their diabetes/HTN/chol improved? Can they decrease/stop some medications. They need to know how to treat the WLS patient who presents to them with abd. pain, N and/or V, constipation, a GI bug. Many patients will call their bariatric surgeon directly with these issues, many will not. A bariatric surgery patient with a GI bug may require IV fluids because they’re not able to drink enough quickly enough to maintain their fluid status. You never want to blindly place a NG tube in these patients as you can rupture the pouch. The size & composition of oral medications are issues. CM: Partner with established centers with good outcomes (COE) Communicate! Assist the patient through the process Partner with health plan & employer Education
  • CHRIS Objectives: Determine impact of bariatric surgery on weight loss, operative mortality, and 4 obesity co morbidities (diabetes, hyperlipidemia, hypertension, and sleep apnea) Reviewed 2738 articles published b/w 1990-2003 136 studies were included representing 22,094 patients Meta-analysis of publications with co morbidity resolution endpoints since 1990 Outcomes were analyzed separately for each bariatric surgery type to account for inter-procedure variability Also extracted weight loss and 30-day mortality This results in lower morbidity and mortality rates compared to morbidly-obese controls, mostly due to lower cardiovascular risk Gastric bypass patients have 89% lower mortality rates compared to morbidly obese controls in the 5-years after the procedure The reduction in co morbidity rates leads to significantly lower healthcare economic utilization and cost
  • As the BMI goes down, the medication costs go down.
  • Comparing 1035 Surgical vs. 5746 Non-surgical M.O. Patients, the Cristou study revealed- Surgery patients had significantly fewer hospitalizations, in-hospital days and outpatient physician visits Direct health care costs were significantly lower in the surgery cohort the bariatric surgery patients had a 89% lower risk of dying in the 5-year follow up period Bariatric surgery patients had significant risk reductions for developing all major categories of chronic conditions
  • Gastric bypass: approximately 0.5% (range per type of bariatric surgery 0.1-1.1%) Hip Replacement Surgery 2.0% CABG 2.0% Cholecystectomy 0.2% Talking Points: This slide addresses the relative mortality risk of gastric bypass surgery. Bariatric surgery is often portrayed in the media as extremely risky, with the mortality rate often cited as evidence. The mortality rate is often erroneously cited in the media as approximately 1%, while published studies actually prove it to be only half that,0.5%. To judge actual relative risk of the surgery, it is helpful to compare it to other common surgeries. The mortality rate for gall bladder removals is approximately 0.1% and the rate for heart bypass surgery is between 1-3%. Even an extremely routine procedure such as gall bladder removal has a death rate of 1 in 1000, yet the media does not attack it as “dangerous and extreme.” The mortality rate compared with heart bypass surgery is especially favorable, given that both procedures save lives and reduce long-term mortality significantly. Even though the mortality rate from heart surgery is several times higher than for gastric bypass, again heart surgery is not considered to be excessively risky. In summary, gastric bypass surgery is not excessively risky compared to other surgeries and their benefits, contrary to the common portrayal in the media. As with any treatment, the risk must be considered in context with the benefit.
  • F as in Fat: How Obesity Polices are Failing in America: 2005. Trust for America’s Health. http://healthyamericans.org/reports/obesity2005/ accessed 12 February 2006. NEEDS TO BE ADDED TO SLIDE AS A REF. CMSA: top 10 Then compare healthiest to fattest Rank State (And 2004 Reported Percentage Percentage of Obesity in of Adult Obesity) Adults 2002-2004 Average 1 Mississippi (29.5) 28.1 2 Alabama (28.9) 27.7 3 West Virginia (27.6) 27.6 4 Louisiana (27.00) 25.8 5 Tennessee (27.2) 25.6 6 (tie) Texas (25.8 -- not Southeastern state) 25.3 6 (tie) Michigan (25.4 -- not Southeastern state) 25.3 6 (tie) Kentucky (25.8) 25.3 9 Indiana (25.5 -- not Southeastern state) 25.2 10 South Carolina (25.1) 25.1 Colorado had the lowest levels at 16.4 percent based on the average of the most recent three years of data. In addition, over 52 percent of adults are either obese or overweight in every state. Twenty-three states have obese plus overweight levels of adults exceeding 60 percent. Mississippi has the highest combined level of obese plus overweight adults at 64.5 percent based on the average of most recent three years of data. Colorado has the lowest at 52.6 percent. Four states -- Arkansas, Illinois, Tennessee, and West Virginia -- have passed legislation enabling schools to test students’ BMI levels as either part of health examinations or physical education activities. Two states, California and Illinois, screen students for risk of type 2 diabetes.
  • References: Wittgrove, AC, and Wesley, GW. Laparoscopic Gastric Bypass, Roux en-Y – 500 Patients: Technique and Results, with 3-60 month follow-up. Obesity Surgery 2000; 10. 233-239 Dresel, A., et al. Establishing a laparoscopic gastric bypass program. American J of Surg 2002; 184: 617-620. Pope,GD, et al. National Trend in Utilization and In-Hospital Outcomes of Bariatric Surgery. J of Gastrointestinal Surgery 2002; vol. 6, No.6: 855-861. Gastrointestinal Surgery for Severe Obesity. NIH Consens Statement Online 1991 Mar 25-27 (cited year month day);9(1):1-20. Brunicardi, FC, et al. The Surgical Treatment of Morbid Obesity. Textbook of Surgery . Chapter 15: 247-254. MacDonald, KG, et al. The Gastric Bypass Operation Reduces the Progression and Mortality of Non-Insulin –Dependent Diabetes Mellitus; J of Gastrointestinal Surgery ; vol: 1, No. 3 1997. Pope, GD, et al. National Trend in Utilization and In-Hospital Outcomes of Bariatric Surgery. J of Gastrointestinal Surgery 2002; vol. 6, No.6: 855-861. American Society of Bariatric Surgery. Rationale for Surgical Treatment for Morbid Obesity. Nov. 29, 2001. 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. Kushner RF. Roadmaps for Clinical Practice: Case Studies in Disease Prevention and Health Promotion - Assessment and Management of Adult Obesity: A Primer for Physicians . American Medical Association, 2003. Pories WJ, Swanson MS, MacDonald KG, 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, Vol. 222, No. 3, pp. 339-352. 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. Pories WJ, Swanson MS, MacDonald KG, 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, Vol. 222, No. 3, pp. 339-352. Rasheid S, Banasiak M, Gallagher SF, et al. Gastric Bypass is an Effective Treatment for Obstructive Sleep Apnea in Patients with Clinically Significant Obesity. Obesity Surgery 2003, 13, pp. 58-61. Potteiger CE, Paragi PR, Inverso NA, et al. Bariatric Surgery: Shedding the Monetary Weight of Prescription Costs in the Managed Care Arena. Obesity Surgery 2004, 14, pp. 725-730. 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. Centers for Disease Control, 2000-2001. Obesity Data - Christou NV, Sampalis JS, Liberman M. Surgery Decreases Long-term Mortality, Mobidity, and Health Care Use in Morbidly Obese Patients. Annals of Surgery 2004, Vol. 240, No. 3, pp. 416-424. Heart Disease Data - Dzavik V, Ghali WA, Norris C, et al. Long-term survival in 11,661 patients with multivessel coronary artery disease in the era of stenting: a report from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) Investigators. American Heart Journal 2001, Vol. 142, No. 1, pp. 119-126. Ibid. Calculations based on obesity rates by state (CDC – 2002) and population (Census Bureau – 2003). Used mortality data from Christou study to extrapolate potential for lives saved. Citation for Christou study: Christou NV, Sampalis JS, Liberman M. Surgery Decreases Long-term Mortality, Mobidity, and Health Care Use in Morbidly Obese Patients. Annals of Surgery 2004, Vol. 240, No. 3, pp. 416-424. http://www.cnn.com/2000/HEALTH/12/05/hip.replacement/ American Academy of Orthopaedic Surgeons, http://orthoinfo.aaos.org/booklet/view_report.cfm?Thread_ID=2&topcategory=Hip http://www.cnn.com/2000/HEALTH/12/05/hip.replacement/ Alt, Susan. Bariatric Surgery May Become a Self-Pay Service. Health Care Strategic Management , December 2003. Ibid. Sampalis JS, Liberman M, Auger S, Christou NV. The Impact of Weight Reduction Surgery on Health-Care Costs in Morbidly Obese Patients. Obesity Surgery 2004, 14, 939-947. Gallagher SF, Banasiak M, Goinzalvo JP, et al. The impact of bariatric surgery on the Veterans Administration healthcare system: a cost analysis. Obesity Surgery 2003; 13(2):245-248. Sampalis JS, Liberman M, Auger S, Christou NV. The Impact of Weight Reduction Surgery on Health-Care Costs in Morbidly Obese Patients. Obesity Surgery 2004, 14, 939-947. Brown, J. Short-Term Effects of Gastric Bypass Surgery on Medical Care Costs. In press, 2004. Conducted by Kaiser Permanente Center for Health Research. Roberts A, King J, Greenway F. Class III Obesity Continues to Rise in African-American Women. Obesity Surgery 2004, Vol. 14, No. 4, pp. 533 – 535. Livingston EH, Ko CY. Socioeconomic characteristics of the population eligible for obesity surgery. Surgery 2004, Vol. 135, No. 3, pp. 288-296. Angus LDG, Cottam DR, Gorecki PJ, et al. DRG, Costs and Reimbursement following Roux-en-Y Gastric Bypass: an Economic Appraisal. Obesity Surgery 2003, 13, 591-595. National Institutes of Health, 2000, 2003.
  • Co-morbidities are resolved, alleviating additional treatment & pharmaceutical costs Fewer hospital & physician visits associated with post surgical care compared to those who don’t have the surgery

Transcript

  • 1. Obesity Management Continuum of Care: Wellness to Bariatric Surgery Christopher Still, DO, FACN, FACP Director, Center for Nutrition & Weight Management DSL#06-0486 © 2006
  • 2. Why all the Interest in Obesity Treatment?
    • Discovery of “obesity genes”
    • Management: Medical / Surgery
    • Epidemic *
  • 3. 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 Population Age 20+ (%) 1960-1962 NHES 1971-197 NHANES I 1976-1980 NHANES II 1988-1994 NHANES III 2003 NHANES Overweight or Obese US Adults BMI 25 - 29.9 BMI  30 NHLBI. Obes Res. 1998;6(suppl 2):51S-209S. Flegal, et al. Int J Obes. 1998;22:39-47. 43.3% 46.1% 46.0% 55.0% 63%
  • 4. Obesity Defined by Body Mass Index (BMI) BMI = Weight (kg)/Height (m 2 ) Behavioral Risk Factor Surveillance System, CDC Morbid Obese: 40+ Obese: 30-39.9 Overweight: 25-29.9 Healthy: 20-24.9
  • 5. Morbid Obesity
    • 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)
    www.asbs.org Trust for America’s Health Facts 2004 http://www.cdc.gov/pcd/issues/2005/jan/04_0087.htm
  • 6. Obesity and Mortality Risk, 1989               2.5 2.5 2.0 2.0 1.5 1.5 1.0 1.0 0 0 20 20 25 25 30 30 35 35 40 40 BMI BMI Mortality Ratio Mortality Ratio 1 1 Moderate Risk Very Low Risk Low Risk Moderate Risk High Risk Very High Risk Digestive and pulmonary disease Cardiovascular and gallbladder disease Diabetes mellitus 1 Adapted with permission from Gray DS. MedClin North Am. 1989;73:1 Men Men Women Women  
  • 7. • Abnormal PFTs Gall bladder disease • PCOS Gout Stroke • Diabetes • Breast, uterus, cervix • Steatosis Phlebitis Medical Co-Morbidities Osteoarthritis PCOS = polycystic ovarian syndrome NASH = nonalcoholic steatohepatitis NIH/NHLBI. September 1998; NIH publication no. 98 4083. Premature Death Depression GERD Pulmonary disease • Obstructive sleep apnea • Hypoventilation syndrome Cardiovascular disease • Hyperlipidemia • Hypertension • Insulin resistance syndrome Cancer • Colon • Prostate Liver disease • NASH • Cirrhosis Gynecologic/Urologic abnormalities • Abnormal menses • Infertility
    • Stress incontinence
  • 8. “ 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
  • 9. The Cost of Obesity Compared to other Chronic Diseases
    • $ Billions
    • Obesity 1 75.0
    • Type 2 Diabetes 2 73.7
    • Coronary heart disease 3 52.4
    • Hypertension 4 28.2
    • Arthritis 5 23.9
    • Breast 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;38:1351 3 Hodgeson TA et al. Medical Care 1999:37:994. 6 Brown ML, et al. Medical Care; 2002;40(suppl): IV-104
  • 10. “ 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
  • 11. 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 insurance Prevention 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-days
    • NBGH (Institute on the Costs and Health Effects of Obesity)
  • 12. Obesity: Greater Rates of Disability Thompson, D.et al. Am J Health Promot 1998;12:120-127 Percent Unable to Work 9.6 5.6 5.9 12.6 7.9 4.7 Healthy Weight Overweight Obese Men Women
  • 13. Consequences of Obesity Are Devastating
    •  risk of morbidity and mortality 1,2
      •  Risk factors
    •  health costs to
      • Patient
      • Healthcare system
    •  workforce productivity 3
      •  absentee rates
      •  employer costs (5%)
    1 Pi-Sunyer FX. Am J Clin Nutr . 1991;53(suppl 1):1595S. 2 Calle EE et al. N Engl J Med . 1999;341:1097. 3 Thompson D et al. American Journal of Health Promotion. 1998;13:120 .
  • 14. Wellness Weight/Medical Management Bariatric Surgery How Is Obesity Treated?
  • 15. 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 Physical Activity Behavior Modification Medications or Surgery
  • 16.
    • 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 Management Treatment Plan
  • 17. Diet and Physical Activity Pavlou KN, et al. Am J Clin Nutr. 1989;49:115-1123 Exercise Nonexercise 0- 2- 4- 6- 8- 10- 12- 14- 16- 1 2 3 4 5 6 7 8 9 10 11 12 30 Treatment (wk) Follow-up (mo) Weight loss/gain (kg) Balanced caloric deficit diet Protein-sparing modified fast
  • 18.  
  • 19. Weight Loss Medications Epocrates Rx Online. San Mateo (CA): Epocrates, Inc. 2003-(cited 2006 Jan 23). http://www2.epocrates.com Zhaoping 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) monitor b/p GI symptoms monitor b/p Concerns 3.6 kg (7.92#) 2.59 kg (5.7#) 4.5 kg (9.9#) Average Weight Loss at 1 yr phentermine Adipex 3 orlistat Xenical 2 sibutramine Meridia 1
  • 20. Success Rate of Various Weight Loss Treatments
    • Conventional (obese)
    • Diet
    • Exercise
    • Behavior Modification
    • Anti-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
  • 21. Bariatric (Obesity) Surgery
  • 22. Why Surgery?
    • Works when all other therapies fail
    • Resolves co-morbidities
    • Standardization of procedures
    • Risk: surgery < maintain morbidly obese
  • 23. * Includes peri-operative (30-day) mortality of 0.4% p-value 0.001 Christou (McGill University, Montreal, Canada) Implication of not managing morbid obesity 89% REDUCTION IN RISK OF DEATH OVER 5 YEARS
  • 24. 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
  • 25. 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
  • 26. 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)
  • 27. 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
  • 28. 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)
  • 29. 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/
  • 30. 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)
  • 31. Communication between Program - PCP, Health Plan & Employer is Imperative for Long-term Success
    • Plan for Surgery
    • Plan for Postoperative Care
    • Plan for Long-term follow up
  • 32. 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
  • 33. Reduction in Medication Costs… 0 50 100 150 200 250 Total DM HTN Prescription Medication Cost Pre-RYGBP Post-RGBP Monthly Prescription Medication Costs before and after RYGBP Potteiger CE, et al. Obesity Surgery, 2004:14:725-730
  • 34. 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)
  • 35. Mortality Rates in Context
    • 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% 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)
  • 36. 1996 Obesity Trends* Among U.S. Adults BRFSS, 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 1991 Ranks 22 nd 23% obese 6% diabetic Ranks last 16.8% obese 4.3% diabetic Ranks #1 29.5% obese 9.6% diabetic
  • 37. 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
  • 38. 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
  • 39.   Conclusion
    • Successful Treatment of the MO patient
      • collaborative effort
          • Bariatric Team
          • (Surgeon, Bariatrician, RD, Mental Health Counselor)
          • Primary Care Physician
          • Health Plan (case manager)
          • Employer
    • All disciplines must work together to ensure an optimal outcome with long-term results
  • 40. 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.html
  • 41.
    • Wittgrove, AC, and Wesley, GW. Laparoscopic Gastric Bypass, Roux en-Y – 500 Patients: Technique and Results,
    • with 3-60 month follow-up. Obesity Surgery 2000; 10. 233-239
    • Dresel, A., et al. Establishing a laparoscopic gastric bypass program. American J of Surg 2002; 184: 617-620.
    • Pope,GD, et al. National Trend in Utilization and In-Hospital Outcomes of Bariatric Surgery. J of Gastrointestinal Surgery
    • 2002; vol. 6, No.6: 855-861.
    • Gastrointestinal Surgery for Severe Obesity. NIH Consens Statement Online 1991 Mar 25-27 (cited year month day);9(1):1-20.
    • Brunicardi, FC, et al. The Surgical Treatment of Morbid Obesity. Textbook of Surgery . Chapter 15: 247-254.
    • MacDonald, KG, et al. The Gastric Bypass Operation Reduces the Progression and Mortality of Non-Insulin –Dependent
    • Diabetes Mellitus; J of Gastrointestinal Surgery ; vol: 1, No. 3 1997.
    • Pope, GD, et al. National Trend in Utilization and In-Hospital Outcomes of Bariatric Surgery. J of Gastrointestinal Surgery
    • 2002; vol. 6, No.6: 855-861.
    • American Society of Bariatric Surgery. Rationale for Surgical Treatment for Morbid Obesity. Nov. 29, 2001.
    • 1.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.
    • 2.Kushner RF. Roadmaps for Clinical Practice: Case Studies in Disease Prevention and Health Promotion - Assessment and Management of Adult Obesity: A Primer for Physicians . American Medical Association, 2003.
    • 3.Pories WJ, Swanson MS, MacDonald KG, 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, Vol. 222, No. 3, pp. 339-352.
    • 4.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.
    • 5.Pories WJ, Swanson MS, MacDonald KG, 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, Vol. 222, No. 3, pp. 339-352.
    • 6.Rasheid S, Banasiak M, Gallagher SF, et al. Gastric Bypass is an Effective Treatment for Obstructive Sleep Apnea in Patients with Clinically Significant Obesity. Obesity Surgery 2003, 13, pp. 58-61.
    • 7.Potteiger CE, Paragi PR, Inverso NA, et al. Bariatric Surgery: Shedding the Monetary Weight of Prescription Costs in the Managed Care Arena. Obesity Surgery 2004, 14, pp. 725-730.
    • 8. 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.
    • 9.Centers for Disease Control, 2000-2001.
    Resources
  • 42.
    • 10. Obesity Data - Christou NV, Sampalis JS, Liberman M. Surgery Decreases Long-term Mortality, Mobidity, and Health Care Use in Morbidly Obese Patients. Annals of Surgery 2004, Vol. 240, No. 3, pp. 416-424.
    • Heart Disease Data - Dzavik V, Ghali WA, Norris C, et al. Long-term survival in 11,661 patients with multivessel coronary artery disease in the era of stenting: a report from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) Investigators. American Heart Journal 2001, Vol. 142, No. 1, pp. 119-126. Ibid.
    • Calculations based on obesity rates by state (CDC – 2002) and population (Census Bureau – 2003). Used mortality data from Christou study to extrapolate potential for lives saved. Citation for Christou study: Christou NV, Sampalis JS, Liberman M. Surgery Decreases Long-term Mortality, Mobidity, and Health Care Use in Morbidly Obese Patients. Annals of Surgery 2004, Vol. 240, No. 3, pp. 416-424.
    • http://www.cnn.com/2000/HEALTH/12/05/hip.replacement/
    • American Academy of Orthopaedic Surgeons, http://orthoinfo.aaos.org/booklet/view_report.cfm?Thread_ID=2&topcategory=Hip
    • http://www.cnn.com/2000/HEALTH/12/05/hip.replacement/
    • Alt, Susan. Bariatric Surgery May Become a Self-Pay Service. Health Care Strategic Management , December 2003.
    • Ibid.
    • Sampalis JS, Liberman M, Auger S, Christou NV. The Impact of Weight Reduction Surgery on Health-Care Costs in Morbidly Obese Patients. Obesity Surgery 2004, 14, 939-947.
    • Gallagher SF, Banasiak M, Goinzalvo JP, et al. The impact of bariatric surgery on the Veterans Administration healthcare system: a cost analysis. Obesity Surgery 2003; 13(2):245-248.
    • Sampalis JS, Liberman M, Auger S, Christou NV. The Impact of Weight Reduction Surgery on Health-Care Costs in Morbidly Obese Patients. Obesity Surgery 2004, 14, 939-947.
    • Brown, J. Short-Term Effects of Gastric Bypass Surgery on Medical Care Costs. In press, 2004. Conducted by Kaiser Permanente Center for Health Research.
    • Roberts A, King J, Greenway F. Class III Obesity Continues to Rise in African-American Women. Obesity Surgery 2004, Vol. 14, No. 4, pp. 533 – 535.
    • Kushner RF. Roadmaps for Clinical Practice: Case Studies in Disease Prevention and Health Promotion - Assessment and Management of Adult Obesity: A Primer for Physicians . American Medical Association, 2003.
    • Livingston EH, Ko CY. Socioeconomic characteristics of the population eligible for obesity surgery. Surgery 2004, Vol. 135, No. 3, pp. 288-296.
    • Angus LDG, Cottam DR, Gorecki PJ, et al. DRG, Costs and Reimbursement following Roux-en-Y Gastric Bypass: an Economic Appraisal. Obesity Surgery 2003, 13, 591-595.
    • National Institutes of Health, 2000, 2003.
    Resources