This document discusses the evaluation and management of obesity by gastroenterologists. It covers assessing a patient's readiness to change, obtaining a medical history and physical exam, evaluating lifestyle factors, screening for psychological issues, and the potential role of endoscopy in initial and postoperative evaluation of bariatric surgery patients. Key aspects include using the stages of change model, motivational interviewing techniques, evaluating diet and exercise habits, screening for eating disorders, and being familiar with normal and abnormal postoperative anatomy after different bariatric procedures.

1. Kurdistan Board GEH/GIT Surgery J Club 2020
Supervised by Professor Dr. Mohamed Alshekhani.

2. Introduction:
 With worsening of the obesity pandemic, gastroenterologists will see more
patients with this chronic disease.
 The association between obesity & several GI conditions & the interplay
between obesity pathophysiology&gut hormones, make gastroenterologists
to play an important role in its management.
 Because more patients undergo bariatric surgery, understanding of
postsurgical anatomy & medical / endoscopic management of bariatric
surgical complications is essential.

3. Introduction:
 Obesity has become pandemic,13% worldwide,higher in USA 42.4%
 Obesity is a chronic disease,“a chronic, relapsing, multifactorial &
neurobehavioral disease&increase in body fat promotes adipose tissue
dysfunction & abnormal fat mass physical forces, resulting in adverse
metabolic, biomechanical&psychosocial health consequences.
 BMI of at least 30 kg/m2,class I obesity (BMI 30–34.9 kg/m2), class II
obesity (BMI 35–39.9 kg/m2), class III obesity (BMI $40 kg/m2).
 The use of BMI, is limited in certain populations;elderly, muscular, &
sarcopenic, as it does not distinguish between lean muscle&body fat or its
location.
 Waist circumference may be used,sp for BMI of 25–34, WC of>40 inches
(102 cm) in men & >35 inches (88 cm) in women suggest central obesity,
associated with increased cardiometabolic risk.

4. Introduction:
 Depending on accurate body composition testing(expensive with limited
vailability), Obesity defined as body fat percentage of>25% in men&
>35%in women with the healthy body fat ranging from 8-19% in men
&21–35% in women (depending on age).
 The cutoffs vary based on ethnicity, as BMI >25 &>27 kg/m2 being used to
define obesity in Asian & Middle East populations, respectively, because of
their higher body fat at a lower BMI&earlier appearance of comorbidities

8. Evaluation:initial
 Assess patients’ readiness to change their health behavior using the “Stages
of Change” model, of 5 stages:
 (i) Precontemplation: unaware of the consequences of their behavior
&resistant to change.
 (ii) Contemplation: aware of the consequences&open to change.
 (iii) Preparation: shows anticipation & willi to change within next 6 mons.
 (iv) Action: is in the process of changing their behavior,
 (v) Maintenance: has sustained the new behavior for >6 months.
 For patients in the precontemplation stage, the goal is to help move them to
the contemplation stage before referral to bariatric specialists.
 Motivational interviewing techniques can help motivation:
 5 A’s (Ask, Advise,Assess, Assist&Arrange).
 OARS (Open-ended questions,Affirmations, Reflections&Summaries.

9. Evaluation:medical
 A weight-focused history, physical examination, lab evaluation.
 Weights at specific time points, including around the major life events&the
effectiveness of previous weight loss attempts should be reviewed.
 Certain medications can cause weight gain & should be downtitrated or
substituted with weight neutral drugs.
 On physical examination, BMI, WC, waist-hip ratio& percent body fat
should be measured.
 Signs of obesity-associated medical conditions including hyperpigmented
skin around the neck or axilla (acanthosis nigricans associated with insulin
resistance),hirsutism (PCOS), large neck circumference (>17 inches for
men or>16 inches for women suggesting increased risk of sleep apnea),
thin, atrophic skin (Cushing disease).
 Baseline lab should include electrolytes, renal function, fasting glucose,
hemoglobin,HbA1c, liver enzymes, CBC, lipid panel,TSH, vit D,&urine
albumin.

10. Evaluation:life-style
 Dietary & eating habits; 24-h diet recall, food frequency Qs, or food log.
 Dietary habits including eating patterns (skipping breakfast, eating one
large meal per day, emotional eating&grazing), frequency of eating out, &
grocery shopping details should be evaluated.
 Onset of satiation &period of satiety should be assessed.
 Physical lifestyle; active or sedentary lifestyle& details regarding exercise
(types, duration, frequency).
 Total energy expenditure (TEE);amount of calories burned/day=resting
energy expenditure (REE),thermic effect of meals (TEM)& energy
expenditure from PA(EEPA), broken down into exercise&nonexercise
activity thermogenesis (NEAT).
 TEE= REE(60-75%)+TEM (10%) + (exercise+NEAT) (15-30%).
 REE,energy cost of physio functions at rest(resp, CO, & body temp
reg.TEM(energy for digestion, absorption& disposal of ingested
nutrients;proteins(20%–35%), ,carbohydrates(5%–15%), fats (5%–15%).
 EEPA, of exercise &NEAT, for PA, not sleeping, eating, or exercise.

11. Evaluation:psychological
 Psychiatric history including anxiety, depression, PTSD.
 Assess whether patients suffer from bulimia nervosa, binge eating disorder,
purging disorder (recurrent purging behavior without binge eating), night
eating syndrome,all require referral to amental health specialist.
 Consider using the Eating Disorder Examination Questionnaire for
screening purposes.

12. Evaluation:endoscopic
 For initial evaluation of subgroup of patients with obesity&for those
undergoing bariatric surgery.
 International Federation for the Surgery of Obesity & Metabolic Disorders
recommends preop OGD for all patients with & without GI symptoms,for
HH(Hill Grade I–IV), esophagitis, BE, gastric polyps, gastritis, HP inf,Ca.
 Abnormal OGD likely to be found in at least 55.5% of patients before
bariatric surgery (25.3% for a subgroup of asymptomatic patients) with
16.5% having findings that led to modification or delay of the planned
procedure & 0.2% having surgery cancelled.
 Gastroenterologists should also be familiar with postbariatric surgical
anatomy including normal & abnormal endoscopic findings.
 For RYGB, the pouch &GJ anastomotic sizes,marginal ulceration&
gastrogastric fistula should be documented.
 For SG,sleeve dimension/configs&sleeve stenosis&/or angulation.
 In SG de novo reflux 23%,BE 11%.
 For lapa adj gastric band, retroflexion for band erosion.