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  • “ Obesity is a complex, multi-factorial chronic disease that develops from the interaction between genotype and the environment. Our understanding of how and why obesity occurs is incomplete; however, it involves the integration of social, behavioral, cultural, physiological, metabolic and genetic factors.   There are three key factors to assess the degree of obesity: Body mass index (BMI) Waist circumference Risk factors or comorbidities Obesity causes impaired function and disease in many organ systems, which often can be reversed or prevented by modest weight loss. The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults . National Institutes of Health. National Heart, Lung, and Blood Institute. October 2000, NIH Publication No. 00-4084 Wing RR, Koeske R, Epstein LH, Nowalk MP, Gooding W, Becker D. Long-term effects of modest weight loss in type II diabetic patients. Arch Intern Med. Oct 1987;147(10):1749-1753. 3. Mertens IL, Van Gaal LF. Overweight, obesity, and blood pressure: the effects of modest weight reduction. Obes Res . 2000 May;8(3):270-8. 4. Flechtner-Mors M, Ditschuneit HH, Johnson TD, Suchard MA, Adler G. Metabolic and weight loss effects of long-term dietary intervention in obese patients: four-year results. Obes Res. Aug 2000;8(5):399-402. 5. 4. Ditschuneit HH, Frier HI, Flechtner-Mors M. Lipoprotein responses to weight loss and weight maintenance in high-risk obese subjects. Eur J Clin Nutr. Mar 2002;56(3):264-270.
  • Appropriate obesity therapy involves many of the same principles used in the management of other chronic diseases and requires continued support from physicians and other caregivers as part of a long-term treatment plan. An effective weight loss program combines diet therapy, physical activity, and behavioral modifications. Furthermore, certain patients may benefit from the addition of weight loss drugs to the basic treatment regimen. Bariatric surgery is the most effective available weight loss therapy, but is associated with the highest risk of complications. Therefore, surgery is reserved for patients with severe obesity, who have failed non-surgical attempts to lose weight.
  • Source: The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults . National
  • Source: Jeffery RW, Drewnowski A, Epstein LH. Long-term maintenance of weight loss: current status. Health Psychol . 2000 Jan:19(1 Suppl):5-16. Division of Epidemiology, School of Public Health, University of Minnesota, Twin Cities Campus, Minneapolis 55454-1015, USA. Intervention strategies for promoting long-term weight loss are examined empirically and conceptually. Weight control research over the last 20 years has dramatically improved short-term treatment efficacy but has been less successful in improving long-term success. Interventions (define interventions) in preadolescent children show greater long-term efficacy than in adults. Extending treatment length and putting more emphasis on energy expenditure have modestly improved long-term weight loss in adults. Fresh ideas are needed to push the field forward. Suggested research priorities are patient retention, natural history, assessment of intake and expenditure, obesity phenotypes, adolescence at a critical period, behavioral preference-reinforcement value, physical activity and social support, better linkage of new conceptual models to behavioral treatments, and the interface between pharmacological and behavioral methods.  
  • Perri MG, McAllister DA, Gange JJ, et al.Effects of four maintenance programs on the long-term management of obesity. J Consult Clin Psychol. 1988 Aug;56(4):529-34.
  • The majority of patients initially seek to lose weight through lifestyle changes. Patients who follow an optimal program that uses diet, exercise and behavior modification can expect to achieve and maintain up to a 10% weight loss, if they continue it permanently. some people regain half of their lost weight in a little over one year. [ii] [i] Glenny AM, O’Meara S, Melville A, et al. (1997, September) The treatment and prevention of obesity: a systematic review of the literature. Int J Obes Relat Metab Disord ; 2(9):715-737. [ii] Curioni CC, Lourenco PM. (2005, October) Long-term weight loss after diet and exercise: a systematic review. Int J Obes (Lond); 29(10):1168-1174.
  • As various obesity drugs have entered the market, some patients have used them to supplement their diet and exercise. Obesity drugs fall into two categories: those that 1) prevent the absorption of fat or 2) suppress appetite.  
  • A 2005 meta-analysis of the pharmacologic treatment of obesity found that Sibutramine, Orlistat, Phentermine, and probably Diethylpropion, Bupropion, Fluoxetine and Topiramate promote only modest weight loss ( < 10 pounds) after one year, when given along with recommendations for diet. [i] [i] Li Z, Maglione M, Tu W, et al. Meta-analysis: pharmacologic treatment of obesity. Ann Intern Med . 2005 Apr 5;142(7):532-546. [ii] O’Brien P. (2006) The LAP-BAND Solution: A partnership for weight loss . Melbourne University Publishing Ltd, Australia. Do not sustain long-term weight loss in most patients 1,2 Minority of patients lose 5% to 10% of their weight 1,3 1. Abbott Laboratories. Prescribing Information. Meridia Capsules ; 2006. 2. Bays H, Dujovne C. Pharmacotherapy of obesity: currently marketed and upcoming agents. Am J Cardiovasc Drugs. 2002;2(4):245-253. 3. Roche Laboratories I. Prescribing Information. Xenecal Capsules ; 2007. Additional source: Ioannides-Demos LL, Prioietto J, McNeill JJ. Pharmacotherapy for obesity. Drugs . 2005;65(10):1391-418 Also, for consistency, I have changed everything to “obesity drug”, eliminating “anti-obesity drug”
  • Do not sustain long-term weight loss in most patients 1,2 Minority of patients lose 5% to 10% of their weight 1,3 Side effects create persistence issues Cause insomnia, drowsiness, irritability, or depression 1 Fat absorption drugs can cause muscle cramping, 1 diarrhea, 1 flatulence, 1 and intestinal discomfort 3 Consuming excess amounts of fat while taking those drugs may cause greater intestinal discomfort 2 1. Abbott Laboratories. Prescribing Information. Meridia Capsules ; 2006. 2. Bays H, Dujovne C. Pharmacotherapy of obesity: currently marketed and upcoming agents. Am J Cardiovasc Drugs. 2002;2(4):245-253. 3. Roche Laboratories I. Prescribing Information. Xenecal Capsules ; 2007.
  • Misc- FDA Approved – for long-term use           Xenical (Orlistat) by Roche (http://www.xenical.com)           Alli (OTC, 1/2 dose Xenical) by Roche, GlaxoSmithKline (http://www.roche.com/med-cor-2006-01-24)          Meridia (Sibutramine) by Abbott (http://www.meridia.net)   FDA Approval Pending – for long-term use          Accomplia (Rimonabant) by Sanofi-Synthelabo (http://www.sanofi-aventis.us)   FDA Approved – for short-term use           Accomplia (Rimonabant)          Ionamin (Phentermine)          Adipex-P (Phentermine)          Phentermine (Phentermine)          Bontril (Phentermine)          Didrex (Phentermine)          Tenulate (Phentermine)          Tenuate (Diethylpropion)  
  • FDA Approved – for long-term use           Xenical (Orlistat) by Roche (http://www.xenical.com)           Alli (OTC, 1/2 dose Xenical) by Roche, GlaxoSmithKline (http://www.roche.com/med-cor-2006-01-24)          Meridia (Sibutramine) by Abbott (http://www.meridia.net)   FDA Approval Pending – for long-term use          Accomplia (Rimonabant) by Sanofi-Synthelabo (http://www.sanofi-aventis.us)   FDA Approved – for short-term use           Accomplia (Rimonabant)          Ionamin (Phentermine)          Adipex-P (Phentermine)          Phentermine (Phentermine)          Bontril (Phentermine)          Didrex (Phentermine)          Tenulate (Phentermine)          Tenuate (Diethylpropion)  
  • O’Brien PE, Dixon JB, Laurie C, et al. Treatment of mild to moderate obesity with laparoscopic adjustable gastric banding or an intensive medical program. Ann Intern Med . 2006;144:625-633.
  • Traditional bariatric surgery consists of two types: 1) restrictive and 2) malabsorptive; however, some procedures are a combination of both. Each has its own operative procedures and risks of side effects and/or complications. Most operations can now be done laparoscopically rather than using an open surgical approach.   Malabsorptive procedures, shorten the digestive tract and reduce the absorption of calories (along with proteins and other nutrients).          Biliopancreatic Diversion Restrictive surgery, uses bands or staples to restrict food intake and promote a feeling of fullness (satiety) after eating.          Vertical Banded Gastroplasty           Laparoscopic Adjustable Gastric Banding  Combined procedures, shorten the digestive tract and reduce how much food the stomach can hold.          Roux-en Y Gastric Bypass          Biliopancreatic Diversion with Duodenal Switch     Ad references for the satiety claim
  • Traditional bariatric surgery consists of two types: 1) restrictive and 2) malabsorptive; however, some procedures are a combination of both. Each has its own operative procedures and risks of side effects and/or complications. Most operations can now be done laparoscopically rather than using an open surgical approach.   Restrictive surgery uses bands or staples to restrict food intake and promote a feeling of fullness (satiety) after eating.          Vertical Banded Gastroplasty           Laparoscopic Adjustable Gastric Banding    Malabsorptive procedures shorten the digestive tract and reduce the absorption of calories (along with proteins and other nutrients).          Biliopancreatic Diversion   Combined procedures shorten the digestive tract and reduce how much food the stomach can hold.          Roux-en Y Gastric Bypass          Biliopancreatic Diversion with Duodenal Switch  
  • The First Bariatric Operation: Kremen and Linner's Jejunoileal Bypass: Bariatric surgery continues to evolved since its initial sporadic and tentative introduction in the 1950's. The first bariatric procedure to be preceded by animal studies and subsequently presented to a recognized surgical society and published in a peer reviewed journal was that of Kremen and associates in 1954. (Kremen, Linner et al. 1954) The case which they presented was of a jejunoileal bypass.(JIB). Jejunoileal bypass involved joining the upper small intestine to the lower part of the small intestine, bypassing a large segment of the small bowel, which is thus taken out of the nutrient absorptive circuit. In the discussion of the case, Philip Sandblom of Lund, Sweden, alluded to the fact that, two years previously, Victor Henriksson of Gothenberg, Sweden, had performed a similar procedure for morbid obesity. In this case the redundant small bowel was excised rather than bypassed. Subsequently it was discovered that Dr Richard Varco of the University of Minnesota independently performed JIB at the University of Minnesota Hospitals around the same time as the operation of Kremen et al. Varco's case was unpublished and the patient record lost, so that the exact procedure date is unknown. (Buchwald and Rucker 1984) Essentially, there are four varied approaches to treat morbid obesity through surgery. The earliest procedure developed was known as the jejunalileal bypass . Unfortunately, this procedure is plagued by a high incidence of severe malabsorption. This means that nutrients were not being properly absorbed by the body, leading to extreme diarrhea, mineral and electrolyte imbalances and other problems such as liver cirrhosis. Moreover, many patients have died from the negative effects of this procedure. This procedure is no longer performed due to the high rate of complications. During the 1960s, another procedure known as the vertical banded gastroplasty , a procedure that restricts the gastric system, was developed. Originally, the pouch created had a capacity of approximately 100 to 200 cc's, but doctors found that the size of the pouch impacted the effectiveness of weight loss, so they began to make the pouches smaller. Now pouch sizes are usually 2-4 ounces. Another procedure, gastric stapling , became popular during the 1980s. This surgery inserted several staple lines in the upper portion of the stomach to reduce the volume of intake, then two or three staples were removed to give ingested food the ability to flow through the stomach. The goal was to provide the patient with a feeling of being full when eating, but reduce the number of problems with malabsorption. Although this procedure continued to be modified over the years, including the use of an elastic band to reduce the stomach flow, it has since fallen out of favor. While patients did initially lose weight, maintaining that loss after a couple of years became more difficult because the opening or the band tended to stretch after a while. Source: Kremen AJ, Linner JH, Nelson CH. An experimental evaluation of the nutritional importance of proximal and distal small intestine. Ann Surg 1954;140(3):439-48. The two most common obesity surgeries in the United States have been the Gastric Bypass (GBP) and the Vertical Banded Gastroplasty (VBG). The Gastric Bypass is both a restrictive and malabsorptive operation. With this procedure, the stomach is stapled to make a smaller pouch, then a part of the intestines is attached to it. The result is that you cannot eat as much, and you absorb fewer nutrients and calories from your food. The changes in your stomach and intestine are permanent. Vertical Banded Gastroplasty is a restrictive procedure. The surgeon uses staples to make a small stomach pouch. This reduces how much food the stomach can hold. You feel full sooner and eat less. What you eat is digested by the stomach in the normal way. There is another way to reduce how much food the stomach can hold. It is called the BioEnterics  LAP-BAND  System. Today, Vertical Banded Gastroplasty is being performed less frequently than in the past and is essentially being replaced with the LAP-BAND System because of its adjustability and more gentle approach.
  • Another procedure, gastric stapling , became popular during the 1980s. This surgery inserted several staple lines in the upper portion of the stomach to reduce the volume of intake, then two or three staples were removed to give ingested food the ability to flow through the stomach. The goal was to provide the patient with a feeling of being full when eating, but reduce the number of problems with malabsorption. Although this procedure continued to be modified over the years, including the use of an elastic band to reduce the stomach flow, it has since fallen out of favor. While patients did initially lose weight, maintaining that loss after a couple of years became more difficult because the opening or the band tended to stretch after a while. The two most common obesity surgeries in the United States have been the Gastric Bypass (GBP) and the Vertical Banded Gastroplasty (VBG). The Gastric Bypass is both a restrictive and malabsorptive operation. With this procedure, the stomach is stapled to make a smaller pouch, then a part of the intestines is attached to it. The result is that you cannot eat as much, and you absorb fewer nutrients and calories from your food. The changes in your stomach and intestine are permanent. Vertical Banded Gastroplasty is a restrictive procedure. The surgeon uses staples to make a small stomach pouch. This reduces how much food the stomach can hold. You feel full sooner and eat less. What you eat is digested by the stomach in the normal way. There is another way to reduce how much food the stomach can hold. It is called the BioEnterics  LAP-BAND  System. Today, Vertical Banded Gastroplasty is being performed less frequently than in the past and is essentially being replaced with the LAP-BAND System because of its adjustability and more gentle approach.
  • The two most common obesity surgeries in the United States have been the Gastric Bypass (GBP) and the Vertical Banded Gastroplasty (VBG). The Gastric Bypass is both a restrictive and malabsorptive operation. With this procedure, the stomach is stapled to make a smaller pouch, then a part of the intestines is attached to it. The result is that you cannot eat as much, and you absorb fewer nutrients and calories from your food. The changes in your stomach and intestine are permanent. Vertical Banded Gastroplasty is a restrictive procedure. The surgeon uses staples to make a small stomach pouch. This reduces how much food the stomach can hold. You feel full sooner and eat less. What you eat is digested by the stomach in the normal way.
  • Sources: 1.Mason, EE and Ito C. Gastric bypass in obesity. Surg Clin North Am. 1967 Dec;47(6):1345-51. 2. Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic gastric bypass, Roux-en-Y: preliminary report of five cases. Obes Surg . 1994 Nov 4(4):353-357 Additional resource for substantiating claim Higa KD, Boone KB, Ho T, Davies OG. Laparoscopic Roux-en-Y gastric bypass for morbid obesity: technique and preliminary results of our first 400 patients. Arch Surg . 2000 Sep:135(9):1029-34.
  • The “dumping syndrome” in which food moves too quickly through the small intestine can cause nausea, weakness, sweating, faintness, and sometimes diarrhea after eating.  There can also be an inability to eat sweets without severe weakness and sweating causing patients to lie down to let the symptoms pass.  Dairy intolerance, constipation, headache, hair loss and depression are other possible side effects.1,2 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.
  • This slide is now sourced with the same sources as on the Presentation 1 slides dated 051507, as well as additional sources. Sources: 1. BioEnterics® LAP-BAND® Adjustable Gastric Banding System. System Usage Manual–PN 94163; INAMED Health. 2. University of California, San Diego Medical Center – Center for the Treatment of Obesity. Accessible at http://health.ucsd.edu/specialties/lapband/faq/. 3. Parikh MS, Laker S, Weiner M, et al. Objective comparison of complications resulting from laparoscopic banding procedures. J Am Coll Surg . 2006 Feb; 202(2):252-261. 4. Fisher BL. Comparison of recovery time after open and laparoscopic gastric bypass and laparoscopic adjustable banding. Obes Surg. 2004 Jan;14(1):67-72. 5. O’Brien PE, McPhail T, Chaston TB, Dixon JB. Systematic review of medium-term weight loss after bariatric operations. Obes Surg . 2006 Aug;16(8):1032-1040.   There is another way to reduce how much food the stomach can hold. It is called the LAP-BAND  System. Today, Vertical Banded Gastroplasty is being performed less frequently than in the past and is essentially being replaced with the LAP-BAND System because of its adjustability and more gentle approach. Mean operative time in minutes with the LAP-BAND ® system is less than half of RYGB (61 + 24 min vs 138 + 41 min).(citation?) The LAP-BAND ® System provides effective weight loss comparable to that seen with standard gastric bypass. A recent systematic literature review of 43 published reports and 10,041 operations, showed that weight loss with laparoscopic adjustable gastric banding (LAGB) is comparable to standard Roux-en-Y gastric bypass surgery (RYGB) after three years Fewer total complications than with RYGB or biliopancreatic diversion (BPD) (9% vs 23% with RYGB and 25% with BPD). Fewer major complications than with RYGB or BPD (0.2% vs2% with RYGB and 5% with BPD). Fewer early and late complications with LAP-BAND ® (10.7% vs 27.4% with RYGB and 23.6% with VGB).
  • This is now sourced exactly as it is on Presentation 1 slides dated 051507 Source: Data on File, Allergan, Inc.
  • Although initial weight loss with Gastric Bypass is typically very rapid, at 5 years many LAP-BAND ® System and Gastric Bypass patients achieve comparable weight loss results. 55% of excess weight for the LAP-BAND ® System versus 58% with Gastric Bypass. * O’Brien P, McPhail T, Chaston T, et al. Systematic review of medium-term weight loss after bariatric operations. Obes Surg. 2006: 16; 1032-1040.
  • The name “LAP-BAND ® ” comes from the surgical technique used (laparoscopic, or “keyhole,” surgery) and the name of the product used (gastric band). The LAP-BAND ® System is the only FDA approved weight-loss surgery available and since it’s inception there have been over 250,000 placed world wide. During the LAP-BAND ® System procedure, instruments are placed through very small incisions. The LAP-BAND ® System is fastened like a belt around the upper part of the stomach to create a tiny new stomach pouch. There is no cutting or stapling of the stomach needed in this procedure. The LAP-BAND ® System is connected by tubing to an access port placed under the skin during surgery. Later the surgeon can adjust the LAP-BAND with saline through the access port. With the LAP-BAND ® System the food you eat moves slowly from the small upper pouch to the lower part of your stomach, where it is digested normally. As a result, you eat less food and feel full faster .

M1607 Presentation Transcript

  • 1. Obesity-Related Comorbidities
  • 2. Review of Today’s Topics
    • Overweight and Obesity Classification and Associated Disease Risk
    • Medical Complications of Obesity
    • Cardiovascular Implications
    • Diabetes Implications
    • Weight Loss Makes a Difference
    • Weight Loss Options for Obesity
    • Making the Decision
  • 3. Classification of Overweight & Obesity by BMI, Waist Circumference & Associated Disease Risk*
    • Additional Risks:
    • Large waist circumference (men >40 in; women >35 in) 1
    • Weight gain as little as 11 pounds increases risk of developing type 2 diabetes 2
    • Specific races and ethnic groups 2
    *Disease risk for type 2 diabetes, hypertension, and CVD, relative to normal weight and waist circumference. 1. National Institutes of Health/National Heart, Lung and Blood Institute Clinical Guidelines Evidence Report. NIH Publication 98-4083, September 1998. 2. US Department of Health and Human Services. The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity;2001. Very High 35.0 to 39.9 II High 30.0 to 34.9 I Obesity ≥ 40 25.0 to 29.9 18.5 to 24.9 <18.5 BMI (kg/m 2 ) Disease Risk* Classification 1 Extremely High Increased -- -- III Normal Underweight Extreme Obesity Overweight I
  • 4. Diseases Attributable to Obesity Relative Risk of Developing Certain Diseases Over the Next Decade For Men With BMI >35 1 1. Lopes HF, Egan BM. Autonomic dysregulation and the metabolic syndrome: Pathologic partners in an emerging global pandemic. Arq Bras Cardiol . 2006;87:489-498.
  • 5. Medical Complications of Obesity 1 Pulmonary Disease Abnormal Function Obstructive Sleep Apnea Hypoventilation Syndrome Nonalcoholic Fatty Liver Disease Steatosis Steatohepatitis Cirrhosis Coronary Heart Disease Diabetes Dyslipidemia Hypertension Gynecologic Abnormalities Abnormal Menses Infertility Polycystic Ovarian Syndrome Osteoarthritis Skin Gall Bladder Disease Cancer Breast, Uterus, Cervix, Colon, Esophagus, Pancreas, Kidney, Prostate Phlebitis Venous Stasis Gout Idiopathic Intracranial Hypertension Stroke Cataracts Severe Pancreatitis 1. Obesity OnLine slide presentation. Accessed May 17, 2007. Accessible as slide #5 at http://www.obesityonline.org/slides/slide01.cfm?tk=33.
  • 6. Relationship Between BMI and Cardiovascular Disease Mortality Cardiovascular 1. Abete P, Cacciatore F, Ferrara N, et al. Body mass index and preinfarction angina in elderly patients with acute myocardial infarction. Am J Clin Nutr . 2003;78:796–801.
  • 7. Visceral Fat Cardiovascular Disease Cascade
    • Weight loss in abdominally obese patients is associated with selective mobilization of diabetogenic and atherogenic visceral adipose tissue
    • Simultaneous metabolic improvements associated with mobilization of this tissue may contribute to reduced risk of acute coronary events in high-risk patients
    Cardiovascular Potential benefits of moderate (5 to 10%) weight loss in high risk patients 1 1. Després J-P, Lemieux I, Prud'homme D. Treatment of obesity: need to focus on high risk abdominally obese patients. BMJ . 2001;322:716-20.
  • 8. Abdominal Fat Distribution Increases the Risk of Coronary Heart Disease Waist-Hip Ratio Tertile 1. Folsom AR, Kushi LH, Anderson KE, et al. Associations of general and abdominal obesity with multiple health outcomes in older women: the Iowa Women's Health Study. Arch Intern Med . 2000;160(14):2117-28. Relative Risk Body Mass Index Tertile 3 2 1 The Iowa Women’s Health Study 1 3 2 1 3 2 1 3 2 1 Coronary Heart Disease
  • 9. Risk Factor Sum* and 16-Year Coronary Heart Disease Risk : Framingham Offspring Study 1 Relative Risk of CHD *Low HDL-C, high cholesterol, high BMI, high systolic BP, high triglyceride, high glucose. 1. Wilson PW, Kannel WB, Silbershatz H, et al. Clustering of metabolic factors and coronary heart disease. Arch Intern Med . 1999;159(10):1104-9. 0 Risk Factors (n) 0 1 1 2 > 3 2 > 3 Men Women Coronary Heart Disease
  • 10. Obesity Trends* Among Adults 1. CDC Behavioral Risk Factor Surveillance System. Accessed May 14, 2007. Accessible at http://www.cdc.gov/nccdphp/dnpa/obesity/trend/ maps/index.htm. Behavioral Risk Factor Surveillance System (BRFSS), 1990, 1995, 2000, & 2005 1 * BMI ≥30 or about 30 lbs overweight for 5’4” person. Includes gestational diabetes. No Data <10% 10%-14% 15%-19% 20%-24% 25%-29% ≥30% Diabetes 1990 1995 2005 2000
  • 11. Weight Gain in Adulthood and Risk of Type 2 Diabetes Mellitus 1 1. Willett WC, Dietz WH, Colditz GA. Guidelines for healthy weight. N Engl J Med . 1999;341(6):427-34. Type 2 Diabetes Relative Risk Weight Change (kg) -10 -5 0 5 10 15 20 Men Women
  • 12. Weight Loss Makes a Difference
  • 13. Impact of Weight Loss on Risk Factors 1. Wing RR, Koeske R, Epstein LH, et al. Long-term effects of modest weight loss in type II diabetic patients. Arch Intern Med . 1987;147(10):1749-53. 2. Mertens IL, Van Gaal LF. Overweight, obesity, and blood pressure: the effects of modest weight reduction. Obes Res . 2000;8(3):270-8. 3. Blackburn G. Effect of degree of weight loss on health benefits. Obes Res . 1995;3 Suppl 2:211s-216s. 4. Ditschuneit HH, Frier HI, Flechtner-Mors M. Lipoprotein responses to weight loss and weight maintenance in high-risk obese subjects. Eur J Clin Nutr . 2002;56(3):264-70. 1 2 3 3 1 2 3 3 4 Triglycerides HDL Cholesterol Total Cholesterol Blood Pressure HbA1c 5%-10% Weight Loss ~5% Weight Loss
  • 14. Plasma Lipids Improve With Weight Loss Meta-analysis of 70 Clinical Trials 1 LDL-C=low density lipoprotein cholesterol; HDL-C=high-density lipoprotein cholesterol; TG=triglycerides 1. Dattilo AM, Kris-Etherton PM. Effects of weight reduction on blood lipids and lipoproteins: a meta-analysis. Am J Clin Nutr . 1992;56(2):320-8. * P ≤0.05 Total Cholesterol LDL-C TG HDL-C (weight stable) HDL-C (actively losing)  mmol/L kg of Weight Loss  mg/dL per kg of Weight Loss * * * * * 0.5 0.0 6 -0.5 -1.0 -1.5 -2.0 -2.5 Coronary Heart Disease
  • 15. Relationship Between Change in Weight and Blood Pressure: Trials of Hypertension Prevention II 1 1. Stevens VJ, Obarzanek E, Cook NR, et al. Long-term weight loss and changes in blood pressure: results of the trials of hypertension prevention, phase II. Ann Intern Med . 2001;134(1):1-11. Coronary Heart Disease 1 2 3 4 5 Quintile
  • 16. Relationship Between Weight Change and CHD Risk Factor Sum: Framingham Offspring Study Weight Change During 16-Year Follow-up Coronary Heart Disease 1. Wilson PW, Kannel WB, Silbershatz H, et al. Clustering of metabolic factors and coronary heart disease. Arch Intern Med . 1999;159(10):1104-9. * P <0.002 vs baseline. Change in Risk Factor Sum (%) Men Women +20%* +37% * -48%* -40%* Loss ≥2.25 kg Gain ≥2.25 kg
  • 17. Insulin Sensitivity Improves with Weight Loss in Patients With Type 2 Diabetes 1 1. Wing RR, Koeske R, Epstein LH, et al. Long-term effects of modest weight loss in type II diabetic patients. Arch Intern Med . 1987;147(10):1749-53. * P <0.01 vs before. Diabetes Insulin (pmol/L) Before Weight Loss at 1 Year (% lbs.) * * * 0-2.4 2.5-6.9 7.0-14.0 > 15
  • 18. Modest Weight Loss Prevents Diabetes in Overweight and Obese Persons with Impaired Glucose Tolerance 1 Copyright ©2002. Massachusetts Medical Society. All rights reserved. 1. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med . 2002;346(6):393-403. Cumulative Incidence of Diabetes %) 0 Year 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 Placebo Lifestyle Diabetes
  • 19. Effect of Weight Change on Apnea- Hypopnea Index (AHI) Mean Change in AHI (Events/h) -20 to <-10 (n=22) Change in Body Weight (%) -10 to <-5 (n=39) -5 to <+5 (n=371) +5 to <+10 (n=179) +10 to +20 (n=79) Apnea- Hypopnea 1. Peppard PE, Young T, Palta M, et al. Longitudinal study of moderate weight change and sleep-disordered breathing. JAMA . 2000;284(23):3015-21.
  • 20. Weight Loss Options for Obesity
  • 21. Obesity Overview
    • Obesity is a complex, multi-factorial chronic disease
    • Our understanding of how and why obesity occurs is incomplete but is related to social, behavioral, cultural, physiological, metabolic and genetic factors. 1
    • Modest weight loss (5-10% of body weight) can have considerable medical benefits 2,3,4,5
    Sources: 1. The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults . National Institutes of Health. National Heart, Lung, and Blood Institute. October 2000, NIH Publication No. 00-4084. 2. Wing RR, Koeske R, Epstein LH, Nowalk MP, Gooding W, Becker D. Long-term effects of modest weight loss in type II diabetic patients. Arch Intern Med. Oct 1987;147(10):1749-1753. 3. Mertens IL, Van Gaal LF. Overweight, obesity, and blood pressure: the effects of modest weight reduction. Obes Res . 2000 May;8(3):270-8. 4. Flechtner-Mors M, Ditschuneit HH, Johnson TD, Suchard MA, Adler G. Metabolic and weight loss effects of long-term dietary intervention in obese patients: four-year results. Obes Res. Aug 2000;8(5):399-402. 5. 4. Ditschuneit HH, Frier HI, Flechtner-Mors M. Lipoprotein responses to weight loss and weight maintenance in high-risk obese subjects. Eur J Clin Nutr. Mar 2002;56(3):264-270.
  • 22. Weight Loss Options for Obesity
    • Lifestyle changes (diet, exercise, behavioral modifications) are the cornerstone of therapy
    • Pharmacotherapy can be useful in properly selected patients
    • Bariatric surgery is the most effective long-term therapy for severe or morbid obesity
  • 23. Obesity Treatment Guide Source: The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults . National Institutes of Health. National Heart, Lung, and Blood Institute. October 2000, NIH Publication No. 00-4084. BMI Category (kg/m 2 ) With comorbidities + + 35-39.9 + + 30-34.9 With comorbidities Surgery + With comorbidities Pharmaco-therapy + With comorbidities With comorbidities Diet, Exercise, Behavior Tx > 40 27-29.9 25-26.9 Treatment
  • 24. Short-term Obesity Therapy Does Not Result in Long-term Weight Loss Change in Weight (kg) Source: Wadden TA, Sternberg JA, Letizia KA, et al. Treatment of obesity by very low calorie diet, behavior therapy, and their combination: a five-year perspective. Int J Obes. 1989;13 Suppl 2:39-46 5-Year Follow-up End of Treatment Baseline Diet alone Behavior therapy Combined therapy
  • 25. Long-term Weight Loss is Improved with Long-term Maintenance Therapy Weight Loss (%) Source: Perri MG, McAllister DA, Gange JJ, et al.Effects of four maintenance programs on the long-term management of obesity. J Consult Clin Psychol. 1988 Aug;56(4):529-34. P <0.05 No maintenance tx Maintenance tx Diet and behavior modification therapy 18 I -18 -16 -14 -12 -10 -8 -6 -4 -2 0 0 1 2 3 4 5 6 7 8 9 10 11 12 Time (mo) 13 14 15 16 17
  • 26. Obesity Treatment Pyramid BMI > 40 35 30 25 Diet Physical Activity Lifestyle Modification Pharmacotherapy Bariatric Surgery BMI ≥ 40 35 30 25 Source: The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults . National Institutes of Health. National Heart, Lung, and Blood Institute. October 2000, NIH Publication No. 00-4084.
  • 27. Comparison of Weight Loss Options
    • Lifestyle changes (diet, exercise, behavioral modifications)
    • Pharmacotherapy
    • Bariatric surgery
  • 28. Lifestyle Changes
    • Current weight loss programs use:
      • Diet
      • Exercise
      • Behavior therapy
    • Can be expected to achieve and maintain a weight loss of 5 -10 lbs, if continued
    Source: Tsai AG, Wadden TA. Systematic Review: An Evaluation of Major Commercial Weight Loss Programs in the United States. Ann Intern Med. 2005;142(1):56-66.
  • 29. Lifestyle Changes Tsai AG, Wadden TA. Systematic Review: An Evaluation of Major Commercial Weight Loss Programs in the United States. Ann Intern Med. 2005;142(1):56-66. Evaluation of Major United States Commercial Weight Loss Programs 12 weeks 48 104.7 kg (228 lb) 40 Single-site randomized trial of diabetic patients Health Management Resources 2 years 85 33.7 kg/m 2 423 Multisite randomized trial Weight Watchers 26 weeks 79 38.1 kg/m 2 517 Multisite prospective case series of consecutive participants OPTIFAST 12 weeks Not given 81.9 kg/m 2 234 Multisite randomized trial TOPS Women (%) Mean Initial BMI or Weight Participants (n) Duration Sample Characteristics Study Design Program
  • 30. Lifestyle Changes Tsai AG, Wadden TA. Systematic Review: An Evaluation of Major Commercial Weight Loss Programs in the United States. Ann Intern Med. 2005;142(1):56-66. 7.5 at 1 year 0 -8.4 at 1 year -15.3 at 12 weeks Very low calorie diet using meal replacements 7.5 at 1 year 2.5 -8.4 at 1 year -14.1 at 12 weeks Very low calorie diet using meal replacements and usual foods Health Management Resources 41 at 1 year Not given 0.0 at 1 year -1.0 at 12 weeks Behavior therapy. TOPS leader 38 at 1 year Not given -3.2 at 1 year -2.3 at 12 weeks Behavior therapy, therapist Weight Watchers 27 at 2 years 18 at 1 year 3.2 at 2 years 5.3 at 26 weeks Weight Watchers, group 27 at 2 years 18 at 1 year 0 at 2 years 1.5 at 26 weeks Self-help with 2 visits and a dietitian TOPS 57 at 1.5 years 45 -9.0 at 1.5 years -21.8 at 26 weeks Group counseling and a 12-week very-low- calorie diet Attrition Rate (%) OPTIFAST 67 at 1 year Not given 1.6 at 1 year 0.4 at 12 weeks Usual TOPS program 55 at 1 year Not given 1.0 at 1 year -0.1 at 12 weeks Nutrition therapy, TOPS leader Long Term Initial Long Term Maximum Weight Change (%) Treatment
  • 31. Lifestyle Changes Summary
    • Lifestyle changes include: diet, exercise, behavioral modifications
    • Efficacy of weight loss programs demonstrated in a large, randomized controlled trial has only been seen with Weight Watchers
    • Long-term weight loss is difficult
  • 32. Pharmacotherapy
    • FDA-approved weight-loss drugs
    • Indicated for patients with BMI > 30 or BMI > 27 with other risk factors (eg, hypertension) 1,2
    • Two categories:
      • “ Fat blocker,” eg, orlistat (Xenical ® ) 1
        • Inhibit intestinal enzyme that metabolizes fat
        • Some fat passes undigested through bowels
      • Appetite suppressants, eg, sibutramine (Meridia ® ) 2
        • Act on hunger control centers in the brain
        • Decrease appetite by inhibiting reuptake of serotonin, norepinephrine, and dopamine
    • Sources: 1. Roche Laboratories. Xenical (orlistat) Capsules Prescribing Information. 2007. 2. Abbott Laboratories. Meridia (sibutramine hydrochloride monohydrate) Capsules. 2006.
  • 33. Why Current FDA-Approved Weight-Loss Drugs Don’t Work
    • May not sustain long-term weight loss in most patients 1,2,4
      • Only 2 obesity drugs are approved for long-term weight loss; efficacy beyond 2 and 4 years is unknown as clinical trials are limited
    • Minority of patients lose 5 –10% of their weight 1,3
    • Hunger is not the only trigger for eating
      • Powerful forces drive eating
      • Our culture doesn't just use food for nutritional reasons
      • People eat for comfort
      • Behavior restructuring therapy may be useful in combination
      • Genetics and faulty metabolism
    Sources: 1. Abbott Laboratories. Prescribing Information. Meridia Capsules ; 2006. 2. Ioannides-Demos LL, Prioietto J, McNeill JJ. Pharmacotherapy for obesity. Drugs. 2005;65(10):1391-418. 3. Roche Laboratories I. Prescribing Information. Xenecal Capsules ; 2007. 4. Li Z, Maglione M, Tu W, et al. Meta-analysis: pharmacologic treatment of obesity. Ann Intern Med . 2005 Apr 5;142(7):532-546
  • 34. Limitations of Prescription Weight-Loss Drugs
    • Side Effects
      • With Orlistat, a “fat blocker,” over 20% of patients had one or more of the following side effects: flatulence with fecal discharge, fecal urgency, or fatty, oily stools 1
      • Sibutramine, an amphetamine-like drug, can cause psychological dependence and may interact with many other medications, including certain antibiotics, pain relievers, and antidepressants 2
    • Still…benefits may outweigh risks
    Sources: 1. Roche Laboratories. Xenical (orlistat) Capsules Prescribing Information. 2007. 2. Abbott Laboratories. Meridia (sibutramine hydrochloride monohydrate) Capsules. 2006.
  • 35. Why is it so difficult to bring a weight-loss drug to market?
    • Complexity
      • Etiology of obesity is not well understood
      • No single fat gene that can be turned on/off
      • Multiple targets broaden the market, opening the door for a variety of therapies from several companies
    • Safety and Side Effects
      • Effective drug can have intolerable side effects
    • Reimbursement
  • 36. Why is it so difficult to bring an obesity drug to market?
    • Keeping weight off
      • After initial weight loss, it becomes even more difficult
      • Once the body loses about 10% to 15% of weight, there is a strong urge to go on an eating overdrive to make up for the lost weight
      • Long-term bounce back that has so far been unstoppable
    • Weight maintenance drugs seem to possess the highest potential for success
  • 37. Pharmacotherapy Summary
    • The market for obesity drugs has had a checkered history, characterized by major product withdrawals
    • Statistics suggest a market with enormous opportunity; pharmaceutical companies have so far been unable to capitalize on the opportunity
    • Only 2 drugs are approved for long-term treatment of obesity: Orlistat and Sibutramine
      • Both products have been limited by side effects
    • In the prevailing market there is a clear opportunity for an effective and well-tolerated obesity drug
  • 38. Medical vs Surgical Therapy for Obesity Medical (lifestyle changes and pharmacotherapy) vs Surgical Therapy for Obesity Source: O’Brien PE, Dixon JB, Laurie C, et al. Treatment of mild to moderate obesity with laparoscopic adjustable gastric banding or an intensive medical program. Ann Intern Med . 2006;144:625-633. Weight (lbs.)
  • 39.
    • 2 main types of weight loss procedures:
      • Malabsorptive procedures shorten the digestive tract and reduce the absorption of calories (along with other nutrients)
      • Restrictive procedures use bands or staples to restrict food intake and promote a feeling of fullness (satiety) after eating
    • Some procedures are a combination of both
    Bariatric Surgery
  • 40. Bariatric Surgery Summary
    • Malabsorptive procedures
    • BilioPancreatic Diversion
    • Restrictive procedures
    • Vertical Banded Gastroplasty 
    • Laparoscopic Adjustable Gastric Banding 
    • Sleeve Gastrectomy
    • Combined procedures
    • Roux-en-Y Gastric Bypass
    • BilioPancreatic Diversion with Duodenal Switch
  • 41. Jejunoileal Bypass
    • The first bariatric procedure – 1954
    • Victor Henriksson of Gothenberg, Sweden (1952)
    • Done simultaneously by Kremen/Linner and Richard Varco (University of Minnesota)
    • Induced a state of malabsorption by bypassing most of the intestines while keeping the stomach intact
    • Weight loss was good
    • Complications:
    • Toxic overgrowth of bacteria in the bypassed intestine, liver failure, severe arthritis, skin problems, and flu-like symptoms
    • High incidence of severe malabsorption
    • Extreme diarrhea, mineral and electrolyte imbalances, and liver cirrhosis
    • Many patients died - no longer performed
    • Lessons learned: Long-term follow-up and dangers of malabsorption
    John H. Linner MD, FACS Past President ASBS Source: Kremen AJ, Linner JH, Nelson CH. An experimental evaluation of the nutritional importance of proximal and distal small intestine. Ann Surg 1954;140(3):439-48.
  • 42. Vertical Banded Gastroplasty
    • Developed during the 1960s
    • Purely restrictive procedure
    • Pouch based on lesser curve
    • Introduction of mechanical staples
    • Polypropylene mesh band or Silastic ® ring (nonadjustable)
    • Pouch sizes are usually 2-4 ounces
    • No dumping/malabsorption
    • Adverse Events
      • Relatively low (as is weight loss)
      • Strict diet compliance
      • Frequent vomiting (not adjustable)
      • Not suitable for higher BMI patients
    • Complications
      • Prominent rate of weight regain, severe heartburn, pulmonary emboli, leak, and
      • Myocardial infarction
  • 43. BilioPancreatic Diversion (BPD)
    • AKA Scopinaro Procedure (Hess/Gagner)
    • Removes about 70% of the stomach
    • BPD also diverts fluids and bile produced in the stomach and the first part of the intestines. Diverted enzymes join the ingested food only in the distal small intestine, otherwise known as the ileum
    • Bile and pancreatic secretions flow through the bypassed biliopancreatic channel
    • Distal part of the small intestine is then connected to the pouch, bypassing the duodenum and jejunum
    • After a few months, the patient can eat a completely free diet
    • No restrictive component
    • Long-term nutritional follow-up and patient monitoring needed
    • BPD is an effective and very complicated procedure
  • 44.
    • Complications
      • Less stomach means less acid production=malabsorption
      • Severe malabsorption may lead to nutritional deficiency (must take vitamins and minerals)
      • Risk of deficiency diseases such as anemia and osteoporosis; gallstones are common
      • BPD has a much smaller distance from the stomach to the colon which also promotes malabsorption
      • Should be considered only by patients evaluated by surgeons who are trained in the procedure and perform it routinely
    BPD/Duodenal Switch (BPD/DS)
  • 45. Sleeve Gastrectomy
    • Procedure
    • Stomach turned into a sleeve or tube using staples
    • One- or two-stage procedure
    • 1) Sleeve gastrectomy (High WL)
    • 2) Conversion to gastric bypass/DS (if no WL)
    • Some surgeons prefer it over the gastric banding operation (no foreign body)
    • Complications/Limitations
    • Still fairly new procedure, considered investigational by many surgeons and insurers
    • Irreversible; if weight is not lost, conversion to gastric bypass may be necessary
    Source: www.facs.org/education/gs2004/gs33lee.pdf.
  • 46. Roux en-Y Gastric Bypass Sources: 1.Mason, EE and Ito C. Gastric bypass in obesity. Surg Clin North Am. 1967 Dec;47(6):1345-51. 2. Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic gastric bypass, Roux-en-Y: preliminary report of five cases. Obes Surg . 1994 Nov 4(4):353-357.
  • 47. Roux en-Y Gastric Bypass
    • Dr Roux (France)
    • First performed in 1994 in the United States (Wittgrove/Clark) 2
    • Most common procedure in the US (150,000 in 2005)
    • Both restriction and malabsorption component
    • Small bowel is divided below the lower stomach outlet
    • Rearranged into a Y-configuration via a “Roux limb”
    • Preserves most of the small bowel for nutrients
    • Side Effects
    • May include dumping (nausea, vomiting, diarrhea, abdominal cramps, flushing, and palpitations)
    • Complications
    • Anastomotic leaks, nutritional deficiencies, stomal stenosis, hernia, and death
    Sources: 1.Mason, EE and Ito C. Gastric bypass in obesity. Surg Clin North Am. 1967 Dec;47(6):1345-51. 2. Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic gastric bypass, Roux-en-Y: preliminary report of five cases. Obes Surg . 1994 Nov 4(4):353-357.
  • 48. Bypass Dumping Syndrome 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.
  • 49.
    • Placed around upper part of the stomach 1
      • A small pouch is created 1
      • Stomach holds less food 2
      • Induces feeling of satiety 2
    • OR time may be as little as 1 hour 3
    • Overnight hospital stay may not be needed 3
    • Reduced recovery time 4
    • Evaluated every 4-6 weeks for the first year for gradual tightening
    • As effective as gastric bypass at 36 months and beyond 5
    • Fewer perioperative and less intense complications 3,5
      • Complications include band slippage, erosion and deflation, obstruction of the stomach, dilation of the esophagus, infection, or nausea and vomiting may occur. Reoperation may be required.
    The LAP-BAND ® System Sources: 1. BioEnterics ® LAP-BAND ® Adjustable Gastric Banding System. System Usage Manual–PN 94163; INAMED Health. 2. University of California, San Diego Medical Center – Center for the Treatment of Obesity. Accessible at http://health.ucsd.edu/specialties/lapband/faq/. 3. Parikh MS, Laker S, Weiner M, et al. Objective comparison of complications resulting from laparoscopic banding procedures. J Am Coll Surg . 2006 Feb; 202(2):252-261. 4. Fisher BL. Comparison of recovery time after open and laparoscopic gastric bypass and laparoscopic adjustable banding. Obes Surg. 2004 Jan;14(1):67-72. 5. O’Brien PE, McPhail T, Chaston TB, Dixon JB. Systematic review of medium-term weight loss after bariatric operations. Obes Surg . 2006 Aug;16(8):1032-1040.
  • 50.
    • Advantages
    • 1/10 the short-term mortality rates of open gastric bypass surgery
    • Adjustable–customized per patient
    • Minimally invasive option
    • No stomach stapling, cutting, or intestinal rerouting
    • Reversible
    • Low operative complication rate
    • Low malnutrition risk
    • Satiety-inducing procedure
    • OR time may be as little as 1 hour
    • Overnight hospital stay may not be needed
    • Disadvantages
    • Slower initial weight loss
    • Regular follow-up critical for optimal results
    • Requires an implanted medical device
    • In some cases, band slippage may reduce efficacy
    • In some cases, access port may leak and require additional surgery
    The LAP-BAND ® System Source: Data on File, Allergan, Inc.
  • 51. Comparing Weight Loss Results 1. O’Brien P, McPhail T, Chaston T, et al. Systematic review of medium-term weight loss after bariatric operations. Obes Surg. 2006:16;1032-1040. Laparoscopic adjustable gastric banding (LAGB*) provides effective weight loss, comparable to that seen with standard gastric bypass at 36 months and beyond *LAGB using the LAP-BAND ® System and another adjustable gastric band. Comparison is based on pooled data from 43 peer-reviewed reports involving at least 100 patients at entry and providing at least 3 years of postoperative data.1 NOTE: Excess weight loss with LAGB is comparable to gastric bypass over time. There is not significant difference between weight loss with LAGB and weight loss with gastric bypass at 36 months and beyond.
  • 52. The LAP-BAND ® System – May Help Improve or Resolve Comorbidities
    • In 4 studies, 44%-75% of patients were able to discontinue medications for comorbidity treatment 1-4
    1. Dixon JB, O’Brien PE. Health outcomes of severely obese type 2 diabetic subjects 1 year after laparoscopic adjustable gastric banding. Diabetes Care . 2002;25:358-363. 2. Dixon JB, Chapman L, O’Brien P. Marked improvement in asthma after Lap-Band ® surgery for morbid obesity. Obes Surg . 1999;9:285-389 3. Dixon JB, Schachter LM, O’Brien PE. Sleep disturbance and obesity. Arch Intern Med . 2001;161:102-106. 4. Dixon JB, O’Brien PE. Gastroesophageal reflux in obesity: the effect of Lap-Band placement. Obes Surg . 1999;9:527-531.
  • 53. The LAP-BAND ® System – May Help Improve or Resolve Comorbidities In 4 studies, 90% improvement or resolution of 4 common and serious comorbidities 1-4 1. Dixon JB, O’Brien PE. Health outcomes of severely obese type 2 diabetic subjects 1 year after laparoscopic adjustable gastric banding. Diabetes Care . 2002;25:358-363. 2. Dixon JB, Chapman L, O’Brien P. Marked improvement in asthma after Lap-Band ® surgery for morbid obesity. Obes Surg . 1999;9:285-389 3. Dixon JB, Schachter LM, O’Brien PE. Sleep disturbance and obesity. Arch Intern Med . 2001;161:102-106. 4. Dixon JB, O’Brien PE. Gastroesophageal reflux in obesity: the effect of Lap-Band placement. Obes Surg . 1999;9:527-531.
  • 54. Making the Decision
    • The LAP-BAND ® System
    • Minimally invasive 1
    • Weight loss with LAGB is comparable to gastric bypass over time* 2
    • Lower short-term mortality (up to 10 times lower) and complication rate 3,4
    • Adjustable for long-term satiety 1
    • Reversible 1
    • Requires implanted medical device 1
    • Shorter mean hospital stay and recovery time 3
    • Newer in the United States 1
    • Regular follow-up necessary
    • Gastric Bypass
    • More invasive 1
    • Higher mortality and complication rate 3
    • Nonadjustable 1
    • Difficult to reverse 1
    • Does not require implanted medical device
    • Longer mean hospital stay and recovery 3
    • Longer track record in the United States
    • Less frequent follow-up required
    *LAGB using the LAP-BAND® System and another adjustable gastric band. Comparison is based on pooled data from 43 peer-reviewed reports involving at least 100 patients at entry and providing at least 3 years postoperative data. These data were collected prior to the development and launch of the LAP-BAND AP™ System. 1. Data on File, Allergan, Inc. 2. O’Brien PE, McPhail T, Chaston TB, Dixon JB. Systematic review of medium-term weight loss after bariatric operations. Obes Surg. 2006; 16: 1032-1040. 3. Chapman AE, Kiroff G, Game P, et al. Laparoscopic adjustable gastric banding in the treatment of obesity: A systematic literature review. Surgery . 2004;135(3):326-51. 4. Parikh MS, Laker S, Weiner M, et al. Objective comparison of complications resulting from laparoscopic bariatric procedures. J Am Coll Surg . 2006;202(2):252-61. 5. O’Brien PE, Dixon JB. Lap-Band ® : Outcomes and Results. J Lap Adv Surg Tech . 2003;13(4):265-70.
  • 55. The LAP-BAND ® System Procedure
    • Performed laparoscopically
    • Band is wrapped around the upper part of the stomach
    • Small pouch is created
    • Your stomach holds less food
    • You feel full faster and longer
    Procedure Animation
  • 56. Weight Loss Options for Obesity Summary
    • Lifestyle changes for treating obesity may involve long-term management to sustain weight loss
    • Pharmacotherapy can be useful in properly selected patients
    • For lasting results, bariatric surgery is the most effective therapy for severe or morbid obesity
    • The LAP-BAND ® System offers the benefits of bariatric surgery with minimal complications
    © 2007 Allergan, Inc. Irvine, CA 92612 ® Marks owned by Allergan, Inc. All rights reserved. M1607-01 08/07 RCW