The “TABOO” Disease: Obesity and Your Patient Jeffrey Rosen, MD, FAMSBS, FACS Director Bariatric Surgery Advocate Good Samaritan Hospital LifeWeigh Bariatrics

At the end of this session, participants will: Define obesity/scope of health problems. Describe the fundamental principles of bariatric wellness including treatment options and surgery. Identify key risk management strategies.

Relationship of BMI to Excess Mortality 300 Age at Issue 20-29 250 30-39 200 150 Mortality Ratio 100 Low Moderate High A paper by George Bray examined the relationship of BMI to excess mortality. Data was pooled from 5 prospective studies (3 industrial and 2 community) and included a total sample of 8,422 white males with a mean length of followup of 8.6 years. This slide points out the relationship of BMI to excess mortality. There is a curvilinear increase in excess mortality with rising BMI. The risk is low with a BMI of 25 to30 and increases as BMI increases. The greatest risk is seen with BMIs above 40. 50 Risk Risk Risk 15 20 25 30 35 40 Body Mass Index (kg/[m2]) Bray GA. Overweight is risking fate. Definition, classification, prevalence and risks. Ann NY Acad Sci 1987;499:14-28. BACKGROUND IV

Hypertension Percentage BMI 60 50 40 Percentage 30 20 Data shows results of a population-based longitudinal study by Brown and colleagues. The Australian Longitudinal Study on Women’s Health enrolled 13,431 women who participated in a baseline survey of selected indicators of health and well-being for middle-aged women, age 45-49. The study explored the associations between body mass index and selected indicators of health and well-being; surgical procedures(cholescystectomy, hysterectomy), symptoms like back pain, and number of visits to general practitioners or specialists. BMI was calculated using self-reported height and weight, corrected following the method of Waters. Hypertension shows a strong monotonic relationship with BMI. Trend curve estimates the relationship between BMI and hypertension. The percentage of reported hypertension increases with increasing body mass index. The prevalence of hypertension at different levels of BMI were 10.6%(BMI <20), 13.3% (BMI>20<25), 22.8%(BMI>30<40), and 61.3%(BMI>40). There was a 6-fold increase in the odds ratio of hypertension between women with BMI<20 and women with BMI >40. 10 20 25 30 35 40 BMI Relationship between BMI and crude percentage of women reporting medical problems, surgical procedures, symptoms, and health care utilization. Brown WJ et al. Int J Obes 1998;22:520-528. BACKGROUND V

Diabetes Percentage BMI 15 Percentage 10 5 Diabetes, as described in the study by Brown and colleagues of Australian women , shows a monotonic relationship with BMI. The prevalence of diabetes increases 6-fold between women with a BMI < 20 and women with a BMI > 40. Most of the increase in diabetes prevalence occurs in women with BMI >30. Prevalence is 1.6% at BMI < 20, 1.4% at BMI > 20-< 25, 3.2% at BMI > 25-< 30, 5.9% at BMI > 30-< 40, and 19.3% at BMI > 40. There is a 16-fold increase in the odds ratio for diabetes between women with BMI < 20 and women with BMI > 40. 20 25 30 35 40 BMI Relationship between BMI and crude percentage of women reporting medical problems, surgical procedures, symptoms, and health care utilization. Brown WJ et al. Int J Obes 1998;22:520-528. BACKGROUND V

A key concept of cardiometabolic risk is that the risk factors tend to cluster, as illustrated in this diagram. The cardiovascular and metabolic variables are often associated with each other and therefore can occur simultaneously. In recent years, the clustering of cardiometabolic risk factors has received increasing attention, leading groups such as the World Health Organization, International Diabetes Federation, and the Adult Treatment Panel III (ATP III) (National Cholesterol Education Program) to issue clinical guidelines for identifying this particular group of risk factors as the metabolic syndrome. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA. 2001;285:2486-2497.

Metabolic syndrome: The NCEP ATP III definition* Three or more of the following five risk factors: Risk Factor Defining Level Abdominal obesity Men Women Waist circumference >102 cm (>40 in) >88 cm (>35 in) Triglycerides ≥150 mg/dL (1.7 mmol/L) HDL cholesterol Men Women <40 mg/dL (1.04 mmol/L) <50 mg/dL (1.30 mmol/L) Blood pressure ≥130/ ≥85 mmHg Fasting glucose ≥100 mg/dL (5.6 mmol/L) From the National Heart, Lung, and Blood Institute, part of the National Institutes of Health and the U.S. Department of Health and Human Services. *2001, updated 2005 Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) Final Report. Circulation. 2002;106;3143.

Obesity and CV Disease Pulmonary Hypertension CHF

Ectopic fat deposition Endothelial dysfunction impaired fibrinolysis Diet Physical activity/ Fitness Socioeconomic status Birth size, childhood growth Genes M E T A B O L I C S Y N D R Inflammation Elevated fasting or 2-h post-load glycemia Overweight Hyperuricemia Abdominal obesity/ Ectopic fat deposition Adipose hormones Dyslipidemia Low HDL, high TG High ApoB, low Apo A Small dense LDL Endothelial dysfunction Insulin resistance/ Hyperinsulinemia Hypercoagulability, impaired fibrinolysis Hypertension Hypoandrogenism (men), Hyperandrogenism (women) Diabetes CVD

“Aggressive comprehensive risk factor management improves survival, reduces recurrent events and the need for interventional procedures, and improves quality of life for these patients.” Smith (2006). AHA/ACC Guidelines for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2006 Update. Circulation © 2006 American Heart Association, Inc.

Life’s Simple 7 Never smoked or quit more than one year ago Body mass index less than 25 kg/m2 Physical activity of at least 150 mins (moderate intensity) or 75 mins (vigorous intensity) each week Four to five key components of a healthy diet consistent with current AHA guidelines Total cholesterol of less than 200 mg/dL Blood pressure below 120/80 mm Hg Fasting blood glucose less than 100 mg/dL Ideal cardiovascular health for adults is defined by the presence of these health measures. They’re known as Life's Simple 7. I’ll pause to give you a moment to read the slide. 13 13

Lifetime Risk: Age 50 Men Women 5% 36% 50% 69% 46% 0.7 0.7 0.6 0.6 0.5 2 Major RFs 1 Major RF 1 Elevated RF 1 Not Optimal RF Optimal RFs Lifetime Risk: Age 50 Men Attained Age Adjusted Cumulative Incidence 5% 36% 50% 69% 46% Women 0.7 0.7 0.6 0.6 0.5 50% 0.5 39% 0.4 0.4 Adjusted Cumulative Incidence 0.3 0.3 27% Data shows that if you are a man and you reach the age of 50 with optimal health factors and ideal health behaviors, that you will have less than a 5% chance in your entire lifetime of having a cardiovascular event and if you are a woman that percentage is 8%. So we can help people live longer and with a better quality of life. Many of the advances we have made in the past decade have come through devices and medicines, but the true breakthroughs in the decade ahead will likely lie in preventing the disease to begin with. Today, less than 1 percent of the U.S. population has ideal health as we define it. So preventing the onset of risk factors represents the best strategy to attain a longer life free of disease. So in summary… 0.2 0.2 0.1 0.1 8% 50 60 70 80 90 50 60 70 80 90 Attained Age Lloyd-Jones, Circulation 2006

Philosophies of Weight Loss and Maintenance Must move forward with lifestyle changes for the rest of the patient’s life. “If only I could return to the way I was” Our goal is to strengthen the way patients: Eat, Activity and exercise How they deal with emotional stresses

Obesity Treatment Pyramid Surgery Pharmacotherapy Lifestyle Modification Diet Physical Activity BMI The clinical approach to obesity can be viewed as a pyramid consisting of several levels of therapeutic options. All patients should be involved in an effort to change their lifestyle behaviors to decrease energy intake and increase physical activity. Lifestyle modification also should be a component of all other levels of therapy. Pharmacotherapy can be a useful adjunctive measure for properly selected patients. Bariatric surgery is an option for patients with severe obesity, who have not responded to less-intensive interventions. The number of obese patients who require a specific level of treatment decreases as one moves up the pyramid. Psychological Bariatric and Metabolic Institute l l 16

How Do We Approach the Issue of Wellness/Weight? Activity Exercise Identified the factors associated with the weight Identify potential comorbidities Set up plan “3 COGS” How to Eat Activity and Exercise Psychological Wellness Psychological Eating Surgery or medication

Obesity Treatment Pyramid Surgery Pharmacotherapy Lifestyle Modification Diet Physical Activity BMI The clinical approach to obesity can be viewed as a pyramid consisting of several levels of therapeutic options. All patients should be involved in an effort to change their lifestyle behaviors to decrease energy intake and increase physical activity. Lifestyle modification also should be a component of all other levels of therapy. Pharmacotherapy can be a useful adjunctive measure for properly selected patients. Bariatric surgery is an option for patients with severe obesity, who have not responded to less-intensive interventions. The number of obese patients who require a specific level of treatment decreases as one moves up the pyramid. Psychological Bariatric and Metabolic Institute l l 18

When to start Medications Activity Exercise Drug Therapy Concerns: Efficacy Safety Weight Regain Consideration for starting meds BMI. Comorbid Conditions: DM, HTN, Dyslipidemia &Heart Disease. Adjuncts to diet and exercise. FDA Approval BMI > 30 kg/m2 ( failed diet and exercise alone) BMI 27 – 29.9 ( with comorbidities) Psychological Eating Surgery or medication

Drug Therapy is NOT a Cure of Obesity. What are the Goals ? Normal Body Weight ? Unrealistic ! Success Factors. Weight Loss > 2kg in first month / 1 lb per week. Weight change >5% below baseline in 3-6 months Significant reduction in risk factors with effective weight loss of 5-10 % 10-15 % weight loss = Very Good Response. > 15% weight loss = Excellent Max Duaration of Drug Therapy Published, 4 years with Orlistat.

How Obesity Drugs Work ! Suppress Appetite Early Satiety Alter Fat Digestion How Obesity Drugs Work !

ORLISTAT " Alters Fat Digestion " Common Names Pharmacokinetics Side Effects (15-30%) Prescription 120 mg TID with meal or >30 min postparnadial Over the Counter 60 mg PO TID < 1% is absorbed. Orlistat doesn’t alter Digoxin Phenytoin Warfain ( Except Vit K def ) Glyburide Oral Contraceptives Alcohol Furosemide Captopril Nifedipine Atenolol Cyclosporine may increase in levels Intestinal Borborygmi. Cramps Flatus Fecal Incontinence Oily Spotting Vit A,D,E,K Deficiency Chronic Malabsorption How it works ? Inhibits Pancreatic Lipase

Orlistat Mechanism of Action

Cautions ! Advised to take Vitamin supplements Daily. Monitor Dose of Coumadin as less Vit k is available. GI side effects can be avoided by reducing fat intake < 30 % Should not be used if history of calcium Oxalate Stones. LIVER INJURY ! Rare, FDA revised label in 2009 13 reported, 12 occurred out of USA 40 million worldwide users Causal relationship not extablished But watch for : Itching, Jaundice, Pale color stools, anorexia.

Orlistat - Studies RCT of 800 primary patients 17 centers Orlistat vs usual care >2 years Avg wt loss 8 kg vs 4 kg placebo. lost 5% of initial body weight at year 1 50 % of orlistat patients vs 30% placebo maintained 5% of initial wt loss at year 2 34% of Orlistat vs 24% placebo. Hauptman J.Arch Fam Med. 2009.

Orlistat - Studies Longest trial, 4 year DB trial, 3304 overweight patients. 1st year weight loss 11% in orlistat vs 6% in placebo. Remaining 3 year small regain in both groups. 4 year weight loss 6.9% below initial body weight in orlistat vs 4.1% in placebo. Overall 37% reduction in conversion of patients from impaired GT into DM. In summary initial weight loss is greater and weight gain is slowed by Orlistat as compared to lifestyle/placebo. Diabetes Care.2002;25(6):1033

Weight loss with orlistat

Orlistat - studies Orlistat and “adolescent” population RCT 1 year multicenter trial involving 530 obese adolescents Weight gain of 0.53 kg vs 3.14 kg with placebo. had a categorical BMI reduction of 5% or higher 27% of Orlistat vs 15% of placebo DEXA confirmed fat mass loss. Chanoine JP. JAMA. 2005

Orlistat – Benefits / Practical Summary May be used long – term up to 4 years for weight loss or for weight maintainence in adult obese patients Pediatric indication : 12-16 y/o obese adolescents Less commonly used though can be effective when used properly Use with low-fat diet only, limited use with low carb diet. Vitamin Supplementation is critical and should be taken at least 2 hours pre or post medication use. Improves blood pressure & serum lipid values.

LORCASERIN - “ Appetite reducer “ Common names How it works ? Pharmacokinetics Trade name Belviq 10 mg PO BID Taken with or without food No titration needed Selective serotonin 2C agonist Nonselective serotonin agonists 2A and 2B receptor agonists Fenfluramine Dexfenfluramine Enhanced weight loss More side effects SEROTONIN INDUCED VALVULAR DISEASE. Adverse effects Generally mild Headache - 18% URI - 14.8% Nasopharyngitis – 13.4% Constipation 8% Dizziness – 8% Nausea – 7.5% DM II – May increase symp Hypoglycemia

Cautions ! Should not be used with Creatinine clearance <30 ml/min. Contraindicated in pregnancy. Should not be used with other serotonergics, seratonin syndrome ! SSRI SSNRI Bupropion TCA MAO Inhibitors Caution with Dextromethorphan

Lorcaserin - studies Efficacy similar to Orlistat. RCT 3182 patients (Ave BMI 36) 2 year study. 5% body weight reduction at 1 year 47.5% in lorcaserin vs 20.3% in placebo. At year 2 maintained weight loss 67.9% in locaserin group vs 50.3% in placebo group.

Lorcaserin Benefits / Practical Summary Efficacy similar to Orlistat with fewer side effects. Long term safety data are limited Slight but significant decrease in blood pressures, heart rate, total and LDL cholesterol, c-reactive protein, fibrinogen, fasting blood glucose and insulin levels

SYMPATHOMIMETICS “Satiety stimulators” Exact Mechanism for weight loss “Unknown” GENERIC NAME TRADE NAME DOSE DAILY DOSAGE SERUM HALF-LIFE DEA Phentermine Adipex Fastin Lonomin 15 mg, 30 mg, 37.5 mg 15mg-37.5 mg QD 4-19 hours IV Diethylpropion Tenuate Tepanil 25 mg, 75 mg 25 mg TID, 75 mg QD 4-13 hours Phendimetrazine Bontril 35 mg 35 mg TID 5 hours III

Sympathomimetics Not Recommended ! Potential side effects Tachycardia Increased blood pressure Insomnia Dry mouth Contipation Nervousness Contraindicated with CAD, Hypertension, Hyperthyroidism. Potential for Abuse / Contraindicated with history of drug abuse. Limited duration of use

Phenylethylamines - Studies Meta-analysis of phenteramine and diethylproprion 3.6 kg additional weight loss at 6 M for phenteramine 3.0 kg additional weight loss at 6 M for diethylproprion. Sympathomimetic + longitudinal care ASBP guidelines. Observational cohort 11,000 patients followed up to 5 years. Weight loss 10.2% - 6 Months Weight loss 10.65% - 1 year Weight loss 4.63% - 5 years Li Z. Ann Internal Med. 2005

Weight loss with phentermine

Phenylethylamines - Studies Sympathomimetic + Topiramate + Lifestyle RCT of 700 subjects at 2 years Placebo – 1.8% weight loss (IBW) Phen/Top (7.5/46 mg) - 9.3% weight loss (IBW) Phen/Top (15/92) – 10.5% weight loss (IBW) Improved CV variables and decreased incidence of DM vs placebo. Observational Study of Phentermine on BP 300 patients treated for 52 weeks Phentermine group lost significantly more weight No significant difference in SBP, DBP or HR in phentermine vs untreated. Li Z Ann Internal Med. 2005 Hendricks EJ. Obesity. 2001.

Phenylethylamines – Benefits / Practical Summary Strongest in Efficacy Long term safety not studied. Side effects limits the use. Short term adjunct to lifestyle changes.

Phentermine-Topiramate (XL) What Combination offers ? Improves efficacy, tolerability. Adverse Effects Dry mouth 13.5% Constipation 15% Paresthesia 13.7% Altered taste 7.4% Dose related increased psychiatric and cognitive defecits Tachycardia Contraindicated in Pregnancy ( Monthly HCG) Hyperthyroidisn Glaucoma MAO Inhibitors Caution with history of renal stones 2012 US FDA approved this combo for. BMI ≥ 30 kg/m2 BMI ≥ 27 kg/m2 + at least 1 weight related comorbid condition. Dosage - QD Start with 3.75/23 mg for 14 days 7.5/46 mg for 12 weeks 11.25/69 mg for 14 days. Max dose – 15/92 mg

CONQUER phase 3 Trial Published in Lancet

Bupropion Pros and Cons : Very good antidepressant Smoking cessation ADHD Bupropion Brand name : Wellbutrin, Wellbutrin XL, Zyban Dose : Begin 150 mg PO QD for 3 days Then titrate to 150 mg BID Or 300 mg XL form Dopamine & Norepinephrine reuptake inhibitor Pros and Cons : Very good antidepressant Central acting appetite suppressant Only antidepressant with consistent weight loss May help blunt weight regain in smoking cessation Caution: May lower seizure threshold Do not use in bulimic patients.

Bupropion-Naltrexone Antidepressant Smoking cessation ADHD Bupropion-Naltrexone Dose : Start 1 tablet daily (90mg/8mg) initially week 1; increase by 1 tablet/day each subsequent week until daily maintenance dose of 2 tablets twice daily (360 mg bupropion/32 mg naltrexone) is achieved at the start of week 4 Dopamine & Norepinephrine reuptake inhibitor and Side Effects Nausea, EMsis Constipation Dizziness Insomina Dry mouth diarrhea Pros: Very good antidepressant Central acting appetite suppressant Only antidepressant with consistent weight loss May help blunt weight regain in smoking cessation Cons: Hypoglycemia, inc BP, inc HR, Inc Seizure risk, gluacoma Caution: May lower seizure threshold Do not use in bulimic patients. Contraindicated Uncontrolled hypertension Watch MAOI’s, Benzos, barbs, chronic opiod use Pregnancy

Metformin Dose targeted to tighter glycemic control. Significant more weight loss (1-2 kg) vs placebo Doesn't qualify as a “weight-loss drug” doesn’t produce enough weight loss ( 5 %) Best choice in Diabetics with obesity when indicated Cheap and generic. No hypoglycemia Contraindicated if Creat >1.4 in females and >1.5 in males. Consider ER form to countering GI side effects.

Other Diabetic Drugs - Pramlintide Symlin (SC) DM 1 - 30-60mcg SC QAC DM 2 – 60-120 mcg SC QAC Simulates human Amylin Slows gastric emptying Reduces post prandial glucose surge Improves Hgb A1c. Modest weight loss Weight loss -2.75 and -2.75 kg in patients with or without DM respectively Larger trial, 651 patients with Type 1 DM in additional to insulin therapy Weight decreased 0.4 kg vs 0.8 kg increase in placebo.

Other Diabetic Drugs – GLP-1 Analogs Byetta (Exenatide) / Bydureon (Exenatide ER) Start 5 mcg BID 30-60 min before meals for 1 Month Then increased to 10 mcg BID Victoza (Liraglutide) Start 0.6 mg SQ QD for 1 week Then 1.2 mg SQ QD ( Max 1.8mg QD) Approved for Rx of DM type 2 Mechanism of action : Enhance glucose dependant Insulin release Suppress inappropriate glucagon release Delay Gastric emptying Reduces appetite by directly acting on receptors in hypothalamus

Liraglutide Side effects : Only GLP-1, Approved for weight loss. Increased Risk of Thyroid Medullary Cancer Not for Obese Adolescents Liraglutide Brand name : Saxenda Dose : Begin 0.6 mg SQ daily Increase weekly intervals ( 1.2, 1.8, 2.4 mg ) daily Recommended dose 3 mg daily Not Recommended with severe renal (<30 Cr/Cl) and severe Liver Impairment. Contraindicated in Pregnancy.Hx family medullary cancer, MEA type 2, suicidal history Side effects : GI –Nausea, Vomiting, Constipation in Diabetics Increased lipase, heart rate Hypoglycemia Pancreatitis, Gall Bladder disease.inc lipase Renal Impairment Suicidal Thoughts !

GLP-1 Agonists – Studies - Practical Points RCT 330 Metformin treated diabetics for 30 weeks: Exenatide 10 mcg – weight down 2.8 kg over placebo Exenatide 5 mcg – weight down 1.6 kg over placebo. Great medications for DM and weight loss Weight is one of the side effects of this medication group. Other Side effects : nausea, vomiting, diarrhea, dyspepsia, headache, hypoglycemia. Contraindicated : H/O pancreatitis, gastroparesis, sever renal impairment. Works synergistically with carb controlled dieting. Red Flag ! Acute back pain or vomiting – check for pancreatic enzymes.

GLP-1 and weight loss

GLP-1 and weight loss after 5% weight loss

Obesity with Comorbidities Weight-centric approach Smoking Depression Bupropion Migraines Topiramate Constipation Elevated LDL Orlistat Diabetes Metformin Liraglutide

Official Weight loss with various medications Drug Length of trial Total weight loss Phentermine 13 weeks -6.4 kg Orlistat ≥1 year -5.3 kg Bupropion 24 weeks -8.0 kg Exenatide 24 weeks -2.9 kg Liraglutide 24 weeks -2.8 kg Metformin 1 year -2.8 kg Sibutramine ≥1 year -6.4 kg Lorcaserin 1 year -5.8 kg Phen/Topiramate ≥1 year -10.2 kg Buprop/Naltrex ≥1 year -8.7 kg References: Vilsboll T, Christensen M, Junker AE, et al. Effects of glucagon-like peptide-1 receptor agonists on weight loss: Systematic review and meta-analyses of randomized controlled trials. BMJ 2012; 344:d7771. LeBlanc ES, O'Connor E, Whitlock EP, et al. Effectiveness of primary care-relevant treatments for obesity in adults: A systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med 2011; 155:434.

Meridia Anticonvulsant Amylin

 Timeline of availability of different pharmacotherapies for overweight/obesity treatment in the USA. Fenfluramine, serotonin receptor (5‐HT2B and 5‐HT2C) agonist; sibutramine, serotonin‐norepinephrine‐dopamine reuptake inhibitor; orlistat, gastric and pancreatic lipase inhibitor; phentermine, sympathomimetic amine; topiramate extended release (ER), extended release formulation of an antiepileptic drug; lorcaserin, serotonin receptor (5‐HT2C) agonist; naltrexone/bupropion, opioid receptor antagonist (naltrexone) combined with catecholamine reuptake inhibitor (bupropion); liraglutide 3.0 mg (once daily), GLP‐1 analogue. Phentermine monotherapy is approved for short‐term weight management in the US. Currently, orlistat, naltrexone/bupropion and liraglutide 3.0 mg are approved in Europe. https://www.ncbi.nlm. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4744746/nih.gov/pmc/articles/PMC4744746/

Obesity Treatment Pyramid Surgery Pharmacotherapy Lifestyle Modification Diet Physical Activity BMI The clinical approach to obesity can be viewed as a pyramid consisting of several levels of therapeutic options. All patients should be involved in an effort to change their lifestyle behaviors to decrease energy intake and increase physical activity. Lifestyle modification also should be a component of all other levels of therapy. Pharmacotherapy can be a useful adjunctive measure for properly selected patients. Bariatric surgery is an option for patients with severe obesity, who have not responded to less-intensive interventions. The number of obese patients who require a specific level of treatment decreases as one moves up the pyramid. Psychological Bariatric and Metabolic Institute l l 61

Types of Procedures Restrictive Malabsorptive Mixed Metabolic Food intake is limited by decreasing the effective stomach size or decreasing the amount of food going entering the small bowel Malabsorptive A procedure that creates a physiological condition of decrease absorption of nutrients Mixed Combination of the above Metabolic Treats metabolic diseases ( Insulin resistance, DM, Dyslipidemia)

Evolution of Minimally Invasive Surgery Endoscopic Open Laparoscopic

Who can POTENTIALLY QUALIFY for Metabolic Weight Loss Surgery Age Previous Weight History History and Physical Psychological Assessment Goal/Achievements Team Evaluation and Approval Patient Approval

Decision Making When to Start Surgical Therapy ? Exercise DIET Behavior Modification Surgical Therapy Concerns: Efficacy Safety Weight Regain

Restrictive Procedures

Malabsorption Decrease absorption of nutients Metabolic changes of hormonal mileu

Anatomic modifications as created in the 4 most common bariatric surgery procedures. Gastric banding involves placement of an adjustable gastric band around the proximal part of the stomach. The band is fixed in position by inserting plication sutures anteriorly. The band can be adjusted/tightened over time by injecting fluid into the subcutaneous port connected to the band. Sleeve gastrectomy involves reducing gastric volume by 75% to 80% by resecting the stomach alongside a 30F endoscope beginning 3 cm from the pylorus and ending at the angle of His. The Roux-en-Y gastric bypass involves creation of a 15- to 20-mL gastric pouch, a 150-cm Roux limb, and a 50-cm biliopancreatic limb. The biliopancreatic diversion procedure includes a distal gastrectomy with long Roux-en-Y reconstruction, where the enteroenterostomy is placed ≈50 cm proximal to the ileocecal valve. Both the volume of the gastric remnant and the length of the alimentary limb can be modified to suit the patient’s weight loss goal. Vest A R et al. Circulation. 2013;127:945-959

Endoluminal & Transgastric Benefits for Obesity Treatment Fewer complications and side effects Less invasive treatments delivered in an outpatient setting Lower cost procedures Improved access to treatment Procedures to prevent progression to morbid obesity

Effects of Bariatric Surgery on Cardiovascular Function by Hutan Ashrafian, Carel W. le Roux, Ara Darzi, and Thanos Athanasiou Circulation Volume 118(20):2091-2102 November 11, 2008

Figure 1. Obesity, cardiac failure, and the beneficial role of bariatric surgery. Figure 1. Obesity, cardiac failure, and the beneficial role of bariatric surgery. RV indicates right ventricular; LV, left ventricular. Ashrafian H et al. Circulation. 2008;118:2091-2102

Figure 2. Mechanisms of atherosclerosis and the beneficial role of bariatric surgery. Figure 2. Mechanisms of atherosclerosis and the beneficial role of bariatric surgery. ICAM-1 indicates intercellular adhesion molecule-1; PAI-1, plasminogen activator inhibitor-1. Ashrafian H et al. Circulation. 2008;118:2091-2102

Risk reduction of complications of metabolic syndrome before and 6 years after gastric bypass surgery 217 diabetic patients underwent GB at least 5 year follow up Reduction ( Compared to Framingham and other study risks) Overall risk CVD ↓27% CHD ↓20% MI ↓40% CVA ↓42% Nephropathy ↓45% Retinopathy ↓50% Cardiovascular mortality ↓18% All with p value less than 0.05 Surgery for Obesity and Related Diseases 10 (2014) 576-83 Aminian Cleveland Clinic

Treatments for obesity Eff icacy Endoscopic Balloon & Sleeve Gastrectomy Risk

Comparative Mortality Craniotomy Esophagectomy Pancreatectomy Peds Heart Aortic Aneurysm CABG Hip Replacement 10.7% 9.1% 8.3% 5.4% 3.9% 3.5% 0.3% BARIATRIC SURGERY 0.28% *Adopted from Dimiek et al. JAMA 2004;292:847-851.

Resolution or improvement of comorbidities Only surgery has resulted in weight maintenance for the long-term for severe obesity The Current State of Bariatric Surgery l Feb 18, 2010

Were do we start? Define Goals and resources for accountability, education and reinforcement Weight loss 5% of total body weight Activity level with progress over time to 5 or more days per week Psychological building blocks for stress and anxiety Coping Skills Supportive structure to support patient Next set of goals 5% total body weight Develop studies that measure more than outcome numbers of labs, measurements must include other social factors …….To be continued

Recommendations for managing overweight or obesity by complications and staging. © Reprinted with permission from the American Association of Clinical Endocrinologists. Garber AJ, Abrahamson, MJ, Barzilay JI, et al. AACE/ACE comprehensive diabetes management algorithm 2015. Endocr Pract 2015; 21: 438–447 20.

Algorithm for management of obesity

An Effective Bariatrics Team Patient Therapist Exercise Instruction Registered Dietitians Nurse Practitioner and Physicians/Surgeons Some parts of the team may be offsite and you will be referred to them

References https://www.nih.gov/news-events/nih-research-matters/new- insights-into-bariatric-surgery-obesity   http://asmbs.org/patients/bariatric-surgery-procedures http://jama.jamanetwork.com/article.aspx?articleid=1900516 http://www.ncbi.nlm.nih.gov/pubmed/25182102 http://www.healio.com/endocrinology/obesity/news/online/%7Bd1 949575-4351-47af-ab4a-397ce79f184d%7D/long-term-follow-up- care-for-the-postoperative-bariatric-surgery-patient http://www.giejournal.org/article/S0016-5107(13)01865-8/abstract Endoscopic sleeve gastroplasty Mayo Gut 2014 Apr;63(4);687-695  http://laparoscopy.blogs.com/prevention_management_3/2010/08 /endoluminal-therapies-for-gastroesophageal-reflux-disease-and- obesity.html SAGES   https://www.youtube.com/watch?v=Ho43hPwecnE Aspireassist Obesity and bariatrics for the endoscopist: New techniques https://www.researchgate.net/publication/51760537_Obesity_and _bariatrics_for_the_endoscopist_New_techniques http://gajitz.com/magic-obesity-pill-gastric-bypass-pill-passes- human-trial/ MAGIC PILL Attiva