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

2. 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.

3. 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

5. Hypertension Percentage BMI60 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 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:
BACKGROUND V

6. Diabetes Percentage BMI15
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:
BACKGROUND V

7. 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:

8. 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 ;106;3143.

9. Obesity and CV Disease
Pulmonary Hypertension
CHF

10. 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

11. “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.

12. 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

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

14. 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

15. 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

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

17. 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

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

19. 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.

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

21. 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

22. Orlistat Mechanism of Action

23. 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.

24. 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

25. 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

26. Weight loss with orlistat

27. 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

28. 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 : 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.

29. 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 % Nasopharyngitis – 13.4%
Constipation 8%
Dizziness – 8%
Nausea – 7.5%
DM II – May increase symp Hypoglycemia

31. 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

32. 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.

34. 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

35. 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

36. 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

37. 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

38. Weight loss with phentermine

39. Phenylethylamines - Studies
Sympathomimetic + Topiramate + Lifestyle
RCT of 700 subjects at 2 years
Placebo – 1.8% weight loss (IBW)
Phen/Top (7.5/46 mg) % 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

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

41. 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

42. CONQUER phase 3 Trial
Published in Lancet

43. 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.

44. 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

46. 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.

47. Other Diabetic Drugs - Pramlintide
Symlin (SC)
DM mcg SC QAC
DM 2 – mcg SC QAC
Simulates human Amylin
Slows gastric emptying
Reduces post prandial glucose surge
Improves Hgb A1c.
Modest weight loss
Weight loss and 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.

48. Other Diabetic Drugs – GLP-1 Analogs
Byetta (Exenatide) / Bydureon (Exenatide ER)
Start 5 mcg BID 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

50. 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 !

52. 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.

53. GLP-1 and weight loss

54. GLP-1 and weight loss after 5% weight loss

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

56. Official Weight loss with various medications
Drug Length of trial Total weight loss
Phentermine weeks kg
Orlistat ≥1 year kg
Bupropion weeks kg
Exenatide weeks kg
Liraglutide weeks kg
Metformin year kg
Sibutramine ≥1 year kg
Lorcaserin year kg
Phen/Topiramate ≥1 year kg
Buprop/Naltrex ≥1 year 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.

58. Meridia
Anticonvulsant
Amylin

59.  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.

60. 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

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)

62. Evolution of Minimally Invasive Surgery
Endoscopic
Open
Laparoscopic

63. 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

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

65. Restrictive Procedures

66. Malabsorption Decrease absorption of nutients
Metabolic changes of hormonal mileu

68. 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:

69. 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

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

72. 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:

73. 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:

74. 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) Aminian Cleveland Clinic

76. Treatments for obesity
Eff icacy
Endoscopic
Balloon
&
Sleeve Gastrectomy
Risk

77. 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:

78. 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

79. 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

80. 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 Endocr Pract 2015; 21: 438–447 20.

81. Algorithm for management of obesity

82. 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

83. References
insights-into-bariatric-surgery-obesity
af-ab4a-397ce79f184d%7D/long-term-follow-up- care-for-the-postoperative-bariatric-surgery-patient
Endoscopic sleeve gastroplasty Mayo
Gut 2014 Apr;63(4);  
/endoluminal-therapies-for-gastroesophageal-reflux-disease-and- obesity.html SAGES
Aspireassist
Obesity and bariatrics for the endoscopist: New techniques
_bariatrics_for_the_endoscopist_New_techniques
human-trial/ MAGIC PILL Attiva