Bariatric surgery from morbid obesity to obese morbidity Dr Alexander Miras MRC Clinical Research Fellow Imperial Weight Centre - Charing Cross Hospital Metabolic Imaging Group - Hammersmith Hospital
What s happening in the UK? No money! Some authorities have stopped bariatric surgery Others follow the NICE guidelines (BMI>35 or 40) Others operate only on patients with BMI>50
London underground newspaper
North West London We operate on patients with BMI>35 and: Sleep apnoea/hypopnoea Uncontrolled hypertension/stable CVD Type 2 Diabetes Mellitus Infertility
Case 1 43 year old lady BMI 45 No cardiovascular/respiratory disease No evidence of Type 2 Diabetes 2 children, peri menopausal University lecturer Plays tennis twice a week On Thyroxine 100mcg od
Case 2 43 year old lady BMI 45 No cardiovascular/respiratory disease Impaired fasting glycaemia Fasting glucose 6.8 mmol/l (122.4 mg/dl) Fasting Insulin 20 mu/l 2 children, regular periods University lecturer Plays tennis twice a week On Thyroxine 100mcg od
Case 3 43 year old lady BMI 45 No cardiovascular/respiratory disease No evidence of Type 2 Diabetes 2 children, regular periods University lecturer-just quit Mobilises with crutches, severe knee OA Needs 3 rd party assistance for daily life My quality of life is very poor On Thyroxine 100mcg od and painkillers
Case 4 43 year old lady BMI 45 Home oxygen-cor pulmonale Exercise tolerance 10 meters Type 2 Diabetes with microvascular complications 2 children, regular periods Unemployed House bound Polypharmacy
Case 5 55 year old gentleman BMI 60 Sleep apnoea on CPAP 2 cardiac stents, BP 149/96 Type 2 Diabetes for 5 years HbA1c 10.6% (92.3 mmol/mol) Total cholesterol/hdl ratio 9.2 University lecturer Walks twice a week On 4 agents for T2DM, Antiplatelets, statin, 4 antihypertensives, Thyroxine 100mcg od
Historical Classifications - Sharma AM, Int J Obes 2009
Morbid Obesity Scott and Law 1970
Recent Classifications Before 1985: Metropolitan Life Insurance Company height-weight tables 1985: NIH Consensus Conference recommended the use of BMI 1997: WHO adopts BMI Waist Circumference and Waist-to-Hip ratio also recommended
WHO classification
OBESITY AND MORTALITY RISK 2.5 2.0 Mortality Ratio 1.5 Cardiovascular and Diabetes Mellitus 1.0 0 Moderate Very Low Low Moderate High 20 25 30 35 40 BMI Very High Reprinted from Gray. Med Clin North Am. 1989;73(1):1-13, based on statistical information from Lew et al. J Chron Dis. 1979;32:563-576.
Limitations Lack of sensitivity and specificity No incorporation of comorbidities No measure of functionality, QoL, risk Poor correlation with overall health
Weight Management vs Obese Morbidity Weight management Clinic kg Treatment Stop coming Morbid Obesity Obese Morbidity 9 domain assessment P1 P2 P3 Weight sensitive? Weight resistant? Non-weight related? Therapy specific? Multimodal Strategy
Morbidity and weight loss sensitivity or resistance Metabolic Ventilatory Reproductive CV risk Perceived health status Eating behaviour -5-10 -15-20 -25-30 % weight loss to improve morbidity ADL / QoL Anxiety / depression Body Image dysphoria Economic cost Aylwin 2005
Benefits of a good classification system Stratification of patients Treatment decision making Application of guidelines Audit/Research
Edmonton Obesity Staging System (EOSS) Stage 2 co-morbidity Stage 1 moderate moderate Stage 3 Stage 0 Obesity Stage 4 Sharma AM & Kushner RF, Int J Obes 2009
Edmonton score Sharma et al, IJO 2009
EOSS Predicts Mortality in NHANES III Padwal R, Sharma AM et al. CMAJ 2011
EOSS Predicts Mortality at Every Level of BMI Overweight Padwal R, Sharma AM et al. CMAJ 2011
EOSS Distribution Across BMI Categories NHANES III (1988-1994) Overweight 23 million 50 million 10 million Class III 6 million Padwal R, Sharma AM et al. CMAJ 2011
EOSS Case 1 24 year-old physically active female, BMI of 32 Kg/m 2 no demonstrable risk factors, no functional limitations, or mental health issues Class I, Stage 0 Obesity - Focus on prevention of further weight gain - Health benefits of more aggressive obesity treatment likely marginal Sharma AM & Kushner RF, Int J Obes 2009
EOSS Case 2 32 year-old male BMI of 36 Kg/m 2 hypertension, sleep apnea, depression Class 2, Stage 2 Obesity - Clear benefits of obesity treatment Sharma AM & Kushner RF, Int J Obes 2009
EOSS Case 3 63 year-old male BMI of 54 Kg/m 2 disabling osteoarthritis (wheel chair) severe hypoventilation, fibromyalgia, generalized anxiety disorder Class 3, Stage 4 Obesity - Aggressive obesity treatment unless deemed palliative Sharma AM & Kushner RF, Int J Obes 2009
Good points Incorporates comorbidities, function, QoL, psychology Does not use BMI Management suggestions (?)
Bad points Relies on constantly changing definitions Are the conditions obesity related or not? Subjective parameters Difficult to confidently allocate patients Difficult to capture success of treatment
Aims To study the utility of King s Criteria in assessing obese patients A. Patient health stage scores 144 obese patients assessed before bariatric surgery (BMI48±7) and again 1 year after surgery (BMI 37±7) B. Observer consistency 11 clinicians scored the same 12 patients in the 9 health domains (based on written information)
Obesity Staging Score: Aylwin et al Front Horm Res 2008 Aasheim E et al, Clinical Obesity 2011
Methods Basis for assigning King s Criteria scores: Medical history Clinical examination Test results New Patient Questionnaire
Effects of surgery Aasheim E et al, Clinical Obesity 2011
Observers consistency (%) Intra-Class Correlations Airways BMI CVD Diabetes Economical Functional Gonadal Health status Image of self 0.62 0.93 0.66 0.78 0.86 0.54 0.76 0.51 0.28 Aasheim E et al, Clinical Obesity 2011
Results: summary King s Criteria Captured obesity-related disease and tracked health improvements after weight loss. Reasonable consistency in scoring among clinicians Clinically useful Identifies which patients may gain most from treatment Provides baseline for later comparison Adds structure to MDT communication Shifts focus from losing weight to improving health
Limitations of King s Criteria Relies on constantly changing definitions, but can be adapted Are the conditions obesity related or not? Subjective parameters Potential improvements Refine staging definitions and weigh them Add more domains: Junction of the gastro-esophagus Kidneys Liver
SOS NEJM 2007
Bariatric Surgery and Long-term Cardiovascular Events
Bariatric Surgery and Long-term Cardiovascular Events
Survival Among High-Risk Patients After Bariatric Surgery
RCT At last
Bariatric surgery won t: make you thin make you happy
Bariatric surgery will: make you healthier make you more functional
Acknowledgements Imperial Weight Centre Dr Carel le Roux Mr Torsten Olbers Dr Florian Seyfried Dr Ling Ling Chua Miss Sabrina Jackson Institute of Clinical Sciences Prof Jimmy Bell Dr Tony Goldstone Dr Samantha Scholtz Dr Christina Prechtl Dr Sarah Ali Miss Giuliana Durighel King s College London Dr Simon Aylwin
Case 6 43 year old lady BMI 45 No cardiovascular/respiratory disease No evidence of Type 2 Diabetes 2 children, regular periods, divorced University lecturer-just quit Severe depression, house bound, regular psychiatric follow up On Thyroxine 100mcg od and antidepressants
Case 7 70 year old lady BMI 45 No cardiovascular/respiratory disease No evidence of Type 2 Diabetes 2 children, peri menopausal Retired University lecturer Plays tennis twice a week On Thyroxine 100mcg od
Case 8 43 year old Asian lady BMI 33.9 2 cardiac stents, BP 149/96 Type 2 Diabetes for 5 years HbA1c 10.6% (92.3 mmol/mol) Total cholesterol/hdl ratio 9.2 2 children, regular periods University lecturer Plays tennis twice a week On 4 agents for T2DM, Antiplatelets, statin, 4 antihypertensives, Thyroxine 100mcg od