Bariatric Surgery: A Cost-effective Treatment of Obesity? Shaneeta M. Johnson MD FACS FASMBS 2018 NMA Professional Development Seminar Congressional Black Caucus Foundation Annual Legislative Conference Washington, DC
OBESITY Greater than one-third of U.S. adults are obese Estimated that one third of all children, one half of all black and Hispanic children born in 2000 will develop diabetes Linked to type 2 diabetes, heart disease, hypertension, certain types of cancer and more Prevalence of Childhood and Adult Obesity in the United States, 2011-2012 Cynthia L. Ogden, PhD1; Margaret D. Carroll, MSPH1; Brian K. Kit, MD, MPH1,2; Katherine M. Flegal, PhD JAMA. 2014;311(8):806-814. doi:10.1001/jama.2014.732. The Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report
Obesity costs Estimated annual cost of $147 billion in 2008 $1,500 higher medical costs than those of normal weight Preventive, diagnostic, and treatment services related to obesity Decreased productivity due to absenteeism Presenteeism - decreased productivity Eric A. Finkelstein, Justin G. Trogdon, Joel W. Cohen and William Dietz Annual Medical Spending Attributable To Obesity: Payer-And Service-Specific Estimates Health Affairs 28, no.5 (2009):w822-w831
Obesity as a Disease American Medical Association - recognized obesity as a disease state with multiple pathophysiological aspects requiring a range of interventions to advance obesity treatment and prevention June 2013
Bariatric Surgery [Bariatric surgery] is the most effective treatment to date, resulting in sustainable and significant weight loss along with resolution of weight-related health conditions in up to 80% [of people]. ASMBS/ASGE white paper, 2011 Recommended by the American Diabetes Association (ADA) as a treatment for diabetes
Bariatric Surgery Endorsements
Prevalence of Obesity Prevalence of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2016 Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be compared to prevalence estimates before 2011. *Sample size <50 or the relative standard error (dividing the standard error by the prevalence) 30%.
Prevalence of Obesity in African-Americans Prevalence of Self-Reported Obesity Among Non-Hispanic Black Adults, by State and Territory, BRFSS, 2014-2016 *Sample size <50 or the relative standard error (dividing the standard error by the prevalence) 30%.
The Impact of Obesity Comorbid Diseases Premature Death Disability Obesity Reduced Quality of Life Increased Medical Costs
Obesity-related Disease The Harmful Effects of Obesity Migraines Sleep apnea Asthma Increased chance of developing one of these and/or additional diseases: Liver disease Gallbladder disease Heart disease High blood pressure Type 2 diabetes GERD Menstrual/ Infertility problems Urinary Incontinence Gout Osteoarthritis Venous disease and leg swelling
Risks of Obesity Body mass index (BMI) = Strong predictor of overall mortality BMI > 30 associated with Risk of Premature death BMI 30-35 = Reduced Median survival by 2-4 years Office of the Surgeon General US Department of Health and Human Services. Overweight and Obesity: health consequences Kaplan, L.M. (2003) Body weight regulation and obesity. Journal of Gastrointetinal Surgery. 7(4) pp. 443-51.
Risks of Obesity Cancer Risks Esophageal Cancer Women: 50,500 Men: 34,000 500,000 new US cases by 2030 (estimate) Pancreatic Cancer Colon and Rectal Cancer Thyroid Cancer Breast Cancer Endometrial Cancer Kidney Cancer Obesity and Cancer Risk National Cancer Institute
Minimally Invasive Bariatric Surgery Surgery altering the gastrointestinal tract to cause weight loss Effective means of losing substantial weight and maintaining that weight loss Affects the numerous comorbidities associated with obesity Considered Metabolic Surgery Indicated for severely obese patients
Who is a Surgical Candidate? Category BMI % Over IBW Underweight < 18.5 100 lbs over ideal body weight OR BMI equal to or > 40 Normal 18.5 24.9 Overweight 25.0 29.9 OR BMI equal to or > 35 complicated by other medical conditions eg. diabetes, high blood pressure Obesity (Class 1) Severe Obesity (Class 2) (Class 3) 30 34.9 > 20% 35 39.9 > 100% 40 49.9 Super obesity > 50 > 250%
Bariatric Surgery The numbers Estimate of Bariatric Surgery Numbers, 2011-2017 2011 2012 2013 2014 2015 2016 2017 Total 158,000 173,000 179,000 193,000 196,000 216,000 228,000 Sleeve 17.80% 33.00% 42.10% 51.70% 53.61% 58.11% 59.39% RYGB 36.70% 37.50% 34.20% 26.80% 23.02% 18.69% 17.80% Band 35.40% 20.20% 14.00% 9.50% 5.68% 3.39% 2.77% BPD-DS 0.90% 1.00% 1.00% 0.40% 0.60% 0.57% 0.70% Revision 6.00% 6.00% 6.00% 11.50% 13.55% 13.95% 14.14% Other 3.20% 2.30% 2.70% 0.10% 3.19% 2.63% 2.46% Balloons 0.36% 2.66% 2.75% Published June 2018 The ASMBS total bariatric procedure numbers are based on the best estimation from available data (BOLD,ACS/MBSAQIP, National Inpatient Sample Data and outpatient estimations).
Primary Metabolic and Bariatric Procedures Laparoscopic Gastric Bypass Stomach reduced to size of walnut, attached to jejunum, thereby bypassing a portion of small intestine Limits consumption and absorption of calories Risks: Allergic reactions, pulmonary emboli, deep vein thrombosis, infection, cardiovascular or pulmonary risks, nutritional deficiencies
Primary Metabolic and Bariatric Procedures Sleeve Gastrectomy Stomach divided and stapled vertically, removing a portion stomach, creating banana-shaped pouch Restricts amount of food and consumed and absorbed Risks: GERD, infection, gastritis, pulmonary emboli, nutritional deficiencies
Increased minimally invasive surgery Advanced surgical techniques Bariatric Surgery It s SAFE! American College of Surgeons (ACS) and American Society of Metabolic and Bariatric Surgeons (ASMBS) accreditation program
Bariatric Surgery Low Mortality Rate 1.00% 0.90% 0.80% 0.70% Mortality Rate Gallbladder removal Hip replacement surgery 0.60% 0.50% 0.40% 0.30% 0.20% 0.10% Bariatric Surgery 0.00% Mortality Rate Bariatric Surgery Gallbladder Removal Hip Replacement Surgery Agency for Healthcare Research and Quality (AHRQ (2007), Statistical Brief #23. Bariatric Surgery Utilization and Outcomes in 1998 and 2004.
Bariatric Surgery BMI >30 50% increased risk of premature death Risks of morbid obesity outweigh risks of surgery Bariatric surgery increases lifespan Gastric bypass reduce risk of premature death by 40% Increase life expectancy by 89% U.S. Department of Health and Human Services Office of the Surgeon General. (2007). Overweight and obesity: health consequences Effects of bariatric surgery on mortality in Swedish obese subjects. New England Journal of Medicine. 357 pp741-752 Adams, T. D. et al. (2007) Long-term mortality after gastric bypass surgery. New England Journal of Medicine 357pp.753-761
Bariatric Surgery It s Effective! 60% excess weight at 6 months 77% excess weight at 12 months 50% excess weight at 5 years Wittgrove, A.C., et al. (2000). Laparosocpic gastric bypass, roux-en-y: 500 patients: technique and results, with 3-60 month follow-up. Obesity Surgery. 10(3) pp.223-239
Bariatric Surgery Impact on Mortality Improve or resolve more than 40 obesity-related diseases and conditions % Reduction in mortality 60% reduction 56% reduction Disease/Condition Cancer esp. breast and colon cancer Coronary artery disease 92% reduction Type 2 diabetes 40% overall reduction Overall reduction in gastric bypass patients Adams, T.D. et al. (2007). Long-term mortality after gastric bypass surgery. New England Journal of Medicine. 357 pp.753-761 Christou, N.V., et al. (2008). Bariatric Surgery reduces cancer risk in morbidly obese patients. Surgery for Obesity and Related Diseases. 4(6) pp. 691-95
Bariatric Surgery Medical Outcomes Condition/Disease % Resolved or Improved % Resolved Type 2 Diabetes 86% 76.8% Hypertension 78.5% 61.7% Obstructive Sleep Apnea 85.7% 83.6% Hyperlipidemia 78.5% 61.7% Buchwald, H, et al. (2004). Bariatric surgery: a systematic review and meta-analysis. Journal of the American Medical Association 292(12) pp.1724-1737
Health Benefits of Weight Loss after Bariatric Surgery Quality of Life Life expectancy Diabetes resolved/improved High blood pressure resolved/improved Improved/resolved depression Decreased heart risks
Bariatric Surgery Hypertension Diabetes 33,718 patients, 13 comorbidities with at least 1% prevalence before surgery
Sampalis J.S., et al. (2004). Impact of weight reduction surgery on health care costs in morbidly obese patients. Obesity Surgery. 14(7) pp. 939-47 Cremieux et al (2008) A study of economic impact of bariatric surgery. The American Journal of Managed Care. 14(9) pp 589-596 Economics of Bariatric Surgery Health care costs 29% in 5 years Payers recover bariatric surgery costs within 2-4 years Costs = $11,500 - $26,000 Worker productivity $2,765/year for employers
Bariatric Surgery in African-Americans Obesity is highest among African-American populations Obese African-American patients have a higher prevalence of obesity-related comorbidities Most patients undergoing bariatric surgery are Caucasian
Bariatric surgery outcomes in black patients with super morbid obesity Significant decrease in weight and BMI Significant improvement or resolution of hypertension, type 2 diabetes and hyperlipidemia 400 350 300 250 200 150 100 50 0 60 50 40 30 20 10 0 Weight (lbs) Preoperative Weight Postoperative Weight Weight (lbs) BMI kg/m2 Preoperative BMI Postoperative BMI BMI kg/m2 Onyewu, Fullum et. Al Bariatric surgery outcomes in black patients with super morbid obesity: a 1-year postoperative review
STAMPEDE Trial 150 patients underwent either intense medical therapy, or gastric bypass or sleeve gastrectomy
STAMPEDE TRIAL HgbA1c of <6.0 at five years Surgery- 29% Medical 5% Weight loss Surgery -23% Medical 5% 88% of insulin at 5 years in surgical arm Decreased diabetic and cardiac meds Surgery-35% Medical-13%
Morehouse School of Medicine Comprehensive Bariatric Surgery Program Nutritional counseling Psychological counseling Partnerships with Sleep medicine, Endocrinology, Cardiology, Pulmonary, and more Optimal Wellness Program Stress medicine Exercise physiology Nutritional counseling
Bariatric Surgery Effective means for resolution of obesity Significant effect on obesity-related diseases Effective treatment for African-Americans with obesity and comorbidities Most effective as part of a comprehensive obesity approach