Riverside Medical and Surgical Weight Loss Center David Salzberg, M. D Riverside Medical and Surgical Weight Loss Center David Salzberg, M.D., Bariatric Surgeon Felice Haake, D.O., Medical Bariatrician 757-637-7637

60% (34 million) of Americans are overweight

25% of American children are overweight

6% of health care expenditures ($238 billion / year)

Obesity Trends* Among U.S. Adults BRFSS, 1985 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

Obesity Trends* Among U.S. Adults BRFSS, 1992 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. Adults BRFSS, 1999 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends* Among U.S. Adults BRFSS, 2006 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Trends* Among U.S. Adults BRFSS, 2009 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Economic….. National cost = $200 billion $93 Billion in medical bills $33 Billion on weight-loss products $74 Billion in “Absenteeism” Obesity can impact different areas of your life. Some overweight people have reported that they have had trouble getting a job. Others feel that people make judgments about their character based on their weight. It appears obesity is the last acceptable form of social discrimination. Obesity impacts our nations economy by increasing medical related costs and causing employees to miss work because of health reasons. You may find that your personal expenses have also increased due to prescription drugs, money spent on weight loss products or other of pocket medical costs. Perhaps most importantly, obesity will effect your health. For many years, scientists and doctors have known that obesity is a health risk. Other well-known health risks include smoking and heavy drinking. Until recently, however, no one knew whether one of these problems was any riskier than the others. A recent study compared obesity with other known health risks: smoking, heavy drinking, and poverty, and reported that obesity is the most serious problem.* In fact, the increase in health problems due to obesity is similar to what is seen in 20 years of aging. *Highlights of the results of this study are available at http://www.rand.org/publications/RB/RB4549.

The Personal Cost of Obesity Change in the cost of living after weight-loss surgery can be dramatic ITEMS Estimated Annual Costs Mean medical/drug costs (BMI  35)1 $ 5,965 Out-of-pocket healthcare expenses2 $ 2,182 Employment inactivity costs3 $ 900 Commercial weight loss program fees4 $ 600 Prescription co-pays (5 meds at $10) Grocery and dining costs5 $ 5,321 TOTAL $15,568 Despite the benefits of loosing weight, some people worry about being able to pay for LAP-BAND surgery. But what most people don’t realize is just how much is costs to be seriously overweight. Between the costs of medication, doctor visits, groceries and weight loss program fees your weight can cost your over $15,000 a year. We know that better health and emotional satisfaction are priceless benefits, but loosing weight can dramatically lower your cost of living expenses. References: 1. Health Management Research Center, University of Michigan, 2001; 2. U.S. Bureau of Labor Statistics, Consumer Expenditures in 2001; 3. Source: Colditz, GA. “Economic costs of obesity and inactivity,” Med Science Sports Exercise, 1999; 4. Marketdata Enterprises, Inc., 10/02; 5. U.S. Bureau of Labor Statistics, Consumer Expenditures in 2001

300,000 deaths annually

Prevalence of Medical Co-Morbidities Attributable to Obesity Sources: Bariatric Surgery: A Summary of the Literature, 1990 to 2001

Relative Risk of Cancer - Men

Relative Risk of Cancer- Women

A typical fast food meal Big Mac: 570 kcal Large Fries: 540 kcal 32 0z (large) soda: 400 kcal TOTAL 1510 kcal A 70 kg moderately active man requires 2100 kcal/day (3 meals).

Where Do Patients Fit In? Clinical Terms Used to Describe Various Levels of Body Fat Normal Weight (BMI 18.5 to 24.9) Overweight (BMI 25 to 29.9) Obese (BMI 30 to 34.9) Severely Obese (BMI 35 to 39.9 ) Morbidly Obese (BMI 40 or more) The ideal BMI ranges from 19 to 25. If your BMI is between 25 and 29.9, you are thought to be overweight. If it is between 30 and 39.9, you are obese. If your BMI is 40 or more, you are said to have morbid obesity. The term “morbid” obesity is used because this degree of excess weight may considerably reduce life expectancy and is associated with an increased risk of developing conditions or diseases such as diabetes, high blood pressure, joint problems, gallstones, stroke, heart disease, and psychosocial problems.

Weight Loss at RRMC Medical Surgical Behavioral

Weight Loss Options (Moderately Overweight) Medical Treatment of Obesity Diet low in calories, fat and carbohydrates Exercise 40 minutes 5 times per week Behavior Modification eat 3 sensible meals per day, avoid snacking, meal replacement There are several options for treating obesity. The most common approaches for losing weight are diets, exercise and weight loss drugs. Studies show that diets and weight loss aids rarely work in helping severely overweight people reach the goal of long-lasting weight loss while professionally supervised diets that include prescription drugs show an average loss of only 6-9% of excess body weight.

Two Options Accelerated Weight Loss The use of pre-packaged meal replacements and supplements to achieve fast results. Lean&Clean A whole foods approach to weight loss and lifelong health.

Where Do Patients Fit In? Clinical Terms Used to Describe Various Levels of Body Fat Normal Weight (BMI 18.5 to 24.9) Overweight (BMI 25 to 29.9) Obese (BMI 30 to 34.9) Severely Obese (BMI 35 to 39.9 ) Morbidly Obese (BMI 40 or more) The ideal BMI ranges from 19 to 25. If your BMI is between 25 and 29.9, you are thought to be overweight. If it is between 30 and 39.9, you are obese. If your BMI is 40 or more, you are said to have morbid obesity. The term “morbid” obesity is used because this degree of excess weight may considerably reduce life expectancy and is associated with an increased risk of developing conditions or diseases such as diabetes, high blood pressure, joint problems, gallstones, stroke, heart disease, and psychosocial problems.

Challenge with Medical Therapy Rebound

Problems with Conservative WL in Morbidly Obese Most patients (95-97%) regain most or all of the weight that was lost within 1 year following diet or drug treatment The average amount of weight loss is relatively small -- 10-40 pounds Drug therapy may be associated with severe complications (Fen-Phen and heart disease)

Weight Loss Surgery Average 55% loss of excess body weight OVER LIFETIME

Surgery for morbid obesity? Why? Calories OUT must be > Calories IN Restrict Malabsorb

Most Common Surgical Options Gastric Bypass (GBP) Sleeve Gastrectomy Band System The two most common obesity surgeries in the United States are the Gastric Bypass (GBP) and the LAP-BAND System. 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. The LAP-BAND System is a restrictive and adjustable procedure. During surgery the LAP-BAND is placed around the upper part of the stomach to create a new tiny stomach pouch. As a result, patients experience an earlier sensation of fullness and are satisfied with smaller amounts of food. There are no permanent changes made to your stomach or intestines and the LAP-BAND can be adjusted through an access port below the surface of the skin. Restrictive and Malabsorptive Restrictive Restrictive and Adjustable

Gastric Bypass (Roux-en-Y) (43644)

LAGB Procedure (43770) 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 200,000 placed world wide. During the LAP-BAND System procedure, instruments are placed through very small incisions. The LAP-BAND is fastened like a wrist watch 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 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 the food you eat moves slowly from the small upper pouch, past the elastic band, and on to the lower part of your stomach, where it is digested normally. As a result, you eat less food and feel full faster.

Sleeve Gastrectomy (43775)

Bariatric Patients at RRMC

Preop Workup Information Session (Free, group or private) Initial Bariatric Consultation (Level 5 Visit) Labs and Imaging Forward to Insurance Carrier

Candidacy? BMI criteria Are at least 18 years old BMI is at least 40 BMI is at least 35 and with combormidities Are at least 18 years old Understand surgery and the risks No uncontrolled psychological conditions Are prepared to attend regular follow-up sessions and make lifestyle changes Consensus of the bariatric team The LAP-BAND System is not right for everyone. You and your surgeon should work together to decide if it is the right treatment for you. Here are some of the things your surgeon will consider.

Insurance Varies by insurance company Varies by patients choice of plan Many large corporations on Peninsula offer coverage Center employs coordinator/insurance specialist who will assist

Insurance Approval This is often the biggest delay! Requirements and lead time vary by company Sufficient documentation of medically supervised diet

Finance Programs Credit Lines through Riverside Your practice must be enrolled in the LAP-BAND System Finance Program. Contact your sales representative for information on how to enroll. Once you are qualified for the procedure you can call INAMED’s toll free number to use a free consulting service; 1-877-LAP-BAND option 4. They will connect your with a lender who will assess your individual financial situation to help secure a loan that matches your needs. The participating lending institutions have competitive interest rates and are large companies focused on funding the LAP-BAND system procedure only. They will not finance Gastric Bypass. While a loan is not guaranteed, the lenders will offer you a variety of secured and unsecured financing options which result in a higher loan approval ratio. Most loans are approved within 1 to 2 business days and funded within 5 to 15 business days. On April 2, 2002, the Internal Revenue Service (IRS) announced a change in its policy regarding how taxpayers may deduct the costs of weight loss or weight control programs. According to the new policy (Revenue Ruling 2002-19), “obesity is medically accepted to be a disease in its own right,” so a taxpayer can now claim weight loss expenses as a medical deduction. Prior to this new ruling, the taxpayer could only include in medical expenses the cost of a weight loss program undertaken at a physician’s direction to treat an existing disease (such as heart disease).

RMWLC Requirements Helpful to have all paperwork regarding past weight loss attempts from PCP Initial questionnaire

Patient Flow- Inpatient To Operating Room Walking night of surgery Drinking day after surgery Home POD 2 Back to work in less than two weeks

Possible Risks and Complications Remember: There are risks associated with any surgery. Categories LAP-BAND Gastric Bypass Sleeve Gastrectomy Major Complications 0.2% 1.4% Mortality Rate 0.11% 0.5% 0.8% Prospective study on lap bariatric procedures with complications categorized using Clavien’s methodology (Clavien P. Proposed classification of complications of surgery with examples of utility in cholecystectomy. Surgery 1992; 111:518-526) for severity scores. Grade 3 and 4 are considered “major.” Grade Definition LAP-BAND RYGB BPD 1 Events carrying minor risk IV for hydration, hospitalized for nausea 2 Events requiring drug therapy, transfusions, hospital stay > 2x median stay Prolonged LOS for post-op edema Leak managed with TPN, PE Pancreatis, delayed gastric emptying 2b Events requiring endoscopy or reop (not requiring organ resection) Port or band revision Reop for bleeding, exploratory lap 3 Events with lasting disability or requiring organ resection Sigmoid esophagus Revision of anastomosis, bowel resection 4 Death Sources: Ren CJ, Laker S, Weiner M, Hajoseuedjavadi O, J Am Coll Surg, v 202, No 2, Feb 2006; ASERNIPS Executive Summary, 2002.

Mortality Mortality Rate Rate (%) 2.00 1.50 1.00 0.50 0.00 Drug Eluding Stent4 Mortality Rate Lap Cholecystectomy4 0.00 0.50 1.00 2.00 Rate (%) Appendectomy4 GI Obstruction4 CABG w/ cath4 Carotid Stent4 Hernia4 Flum1 DeMaria2 Buckwald3 HHS4 1.50

Comparing Weight-Loss Results Gastric Bypass LAP-BAND Although initial weight loss with Gastric Bypass is typically very rapid, surgeons report that at 5 years many LAP-BAND and Gastric Bypass patients achieve comparable weight loss results. 55% of excess weight for the LAP-BAND versus 59% with Gastric Bypass. Source: O’Brien et al. Obesity is a Surgical Disease: Overview of Obesity and Bariatric Surgery, ANZ J Surg, 2004; 74: 200-204.

% Medical Co-Morbidities Resolved after Bariatric Surgery Sources: Bariatric Surgery: A Summary of the Literature, 1990 to 2001

Riverside Medical & Surgical Weight Loss Center Full service metabolic center, under one roof Choice of Medical or Surgical options Dietician, Exercise, Behavioral Access to diagnostics in same building Open, Active correspondence with referring provider 757-637-7637