Medical & Surgical Options for the Bariatric Patient Michelle Mountain, RD, B.Sc Obesity in Canada 1 in 5 adults are obese Six million Canadians are living with obesity 1 in 10 children have clinical obesity A 2010 report estimated that direct costs of overweight and obesity represented $6 billion 4.1 % of Canada s total health care budget 1
Distribution of BMI Categories by Sex, Ages 18 to 79, 2007-2009 Prevalence of Self-Reported Obesity by Age and Sex, Canada, 2007/08 2
Obesity prevalence (%) Pediatric Obesity in Canada: Epidemiology, Etiology and Risks Childhood Obesity in Canadian Children 1 9 8 7 6 5 4 3 2 1979 2004 3-fold increase in obesity in Canadian children Based on measured heights and weights in representative Canadian sample Classified by BMI 95 th percentile 1 0 Shields, 2005 Management and Prevention of Pediatric Obesity in Canada 5 Managing Obesity as a Chronic Disease Injury and disability Western Diet Low Physical activity Medications Obesity Genetics Hormonal imbalances Psychology Stress Sleep Deprivation 3
Managing Obesity as a Chronic Disease 4
Bariatric Medical Program Comprehensive medical care led by an interdisciplinary team Registered Social Worker Registered Dietitian Kinesiologist Medical Internist Non-surgical treatment of obesity, obesity related comorbidities and healthy lifestyle change Bariatric Medical Program Eligibility 18 years of age and older BMI 35 BMI to 30, but less than 35 With at least one of the following comorbidities Type II diabetes mellitus Idiopathic intracranial hypertension Poorly controlled hypertension Ineligibility Current drug or alcohol dependency (within 6 months of referral) Recent major cancer (life threatening, within last 2 years) with active treatment where caloric restriction might exacerbate the condition Untreated or inadequately treated psychiatric illness Patients willing to participate in groups Patients willing to commit to the entire duration of the program 5
Bariatric Medical Program Weight Loss Expectations Lose 5-10% of current weight in 6 months and maintain loss for at least 1 year Average 0.5-1 kg loss per week Bariatric Medical Program: Optifast Program Program Orientation (Group Session) Interdisciplinary Bariatric Team Assessments Behavioral modification/education classes 6
Bariatric Medical Program: Optifast Program CORE PROGRAM: 21 weekly classes Including 12 weeks on Optifast *(4 shakes per day, 5 if BMI more than 55) & 6-7 weeks of supported reintroduction to food * Optifast started in week 2 MAINTENANCE PHASE: Follow up appointment at 6 months (weeks 24/25), 1 year follow-up appointment and 2 year follow up. Support Group from week # 24-52 (6 months). 13 Bariatric Medical Program: Optifast Program Registered Kinesiologist and Registered Nurse Meet with all patients before start of Program Kinesiologist determines patient s suitability for Exercise component of Program blood work done Referral may be made to see RD or RSW Medical Internist (Dr. Glazer) Physical Assessment to determine suitability for Program Review of Blood Work 14 7
What is Optifast? Optifast is a liquid low carbohydrate, low fat and high protein meal substitute Available in chocolate or vanilla flavour (powder form) 4 shakes per day = 900 calories /day Nutritionally complete with the exception of fibre Add inulin fibre supplement Clear fluids with no calories or added sugar are allowed Optifast costs $100 per week NOT covered by OHIP, ODSP, OW or private insurance plans 15 Optifast Group Session Topics Motivation & Goal Setting Building your own Exercise Program Who s Responsible? Support Systems Cognitive Behavioural Therapy Exercise, Diabetes and Hypertension Staying on Track Meal Planning Understanding Nutrition SMART Exercise Dialectical Behaviour Therapy (DBT) Self Esteem Preparing for Transition Exercise and Metabolism Building your own Exercise Program Managing Cues & Triggers Eating Out/Special Occasion Dinning Relapse Prevention Reading labels/shopping Smart Preventing Weight Regain and Plateaus 16 8
SAXENDA What is SAXENDA Contains liraglutide, an analog of human GLP-1 Acts as a GLP-1 receptor agonist Who would benefit from SAXENDA? Adult patients with an initial body mass index (BMI) of: 30 kg/m2 or greater, or 27 kg/m2 or greater in the presence of at least one weight-related comorbidity (e.g., hypertension, type 2 diabetes, or dyslipidemia) and who have failed a previous weight management intervention. Contraindications Personal or family history of medullary thyroid carcinoma or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2) Pregnant or breast-feeding women SAXENDA Weight Loss Excepted How is it taken Side Effect Cost Approximately 8% above lifestyle Injected daily in the evening Maintenance dose of 3.0 mg/day Transient Nausea Approximately $400/month Week 1 Week 2 Week 3 Week 4 Week 5 0.6 mg 1.2 mg 1.8 mg 2.4 mg 3.0 mg 9
A 56 week study SAXENDA Randomized, double-blind, placebo-controlled trial of 3731 patients with obesity or overweight with 1 weight-related comorbidity Once daily Saxenda (n=2437) Placebo (n =1225) + reduced calorie intake (~500 kcal/day deficit) and increased physical activity (150 minutes/week) Patient without diabetes SAXENDA Significant weight loss with Saxenda vs. placebo 64% of patients on Saxenda lost 5% of their weight vs. 27% of patients on placebo (P<0.0001) 33% of patients on Saxenda lost > 10% of their body weight vs. 10% of patients on placebo (P<0.0001) Patients treated with Saxenda mean waist circumference change of 8.2 cm and -4.0 cam with placebo 10
SAXENDA Change from baseline in: Saxenda (n= 2437) Placebo (n= 1225) A1C (%) -0.3-0.1 FPG (mmol/l) - 0.4-0.0 SBP (mmhg) - 4.3-1.5 DBP (mmhg) - 2.7-1.8 Total cholesterol (mmol/l) - 3.2% - 0.9% LDL cholesterol (mmol/l) - 3.1% - 0.7% HDL cholesterol (mmol/l) 2.3 % 0.5% Triglycerides (mmol/l) - 13.6% -4.8% Bariatric Surgery in Canada 11
Bariatric Centres in Ontario Bariatric Centres of Excellence (BCoEs) Regional Assessment and Treatment Centres Surgical Only Sites Humber River Hospital Guelph General Hospital The Ottawa Hospital St. Joseph s Healthcare Hamilton Thunder Bay Regional Healthy Sciences Centre The Toronto Western Hospital Hotel Dieu Hospital Hotel Dieu Grace Hospital Health Science North St Michael s Hospital Toronto St Joseph s Health Care Centre Toronto Michael Garron Hospital Who is considered a candidate for Bariatric Surgery? Ontario Bariatric Network Criteria: BMI 40 and over (based on BMI at time of referral) BMI 35-40 with 1-2 obesity related comorbidities such as diabetes, coronary heart disease, high blood pressure, sleep apnea, etc Multiple failed weight loss attempts Mentally and emotionally prepared for the surgery and understand its benefits, risks and limitations Have support system in place Can demonstrate a commitment to the required lifestyle changes 12
Who is considered a candidate for Bariatric Surgery? Exclusion Criteria: No active eating disorder in place No drug, alcohol or substance abuse in the 6 months prior to surgery Patient s must be smoke free (including e-cigarettes and marijuana) for 6 months to qualify for surgery Untreated major psychiatric disease Women who want to become pregnant within the next 18 months Patient Care Pathway Program Orientation (Group Session) Interdisciplinary Bariatric Team Assessment (RD, RSW, RN, Medical Internist, Physiatrist ) Pre-Operative Testing involving routine blood work and additional diagnostic testing Surgeon Consult and Consent Pre-Operative Assessment Optifast for 2-3 weeks prior to surgery Surgery Post op follow up: 1,3,6, 12 month Yearly up to 5 years 13
Gastric Bypass Sleeve Gastrostomy 14
Duodenal switch (DS) Type 2 Diabetes Resolution Rates Diabetes improvement starts rapidly after surgery, before significant weight loss has occurred. Resolution of Type 2 Diabetes after Gastric Bypass 83.7% The mechanism for postoperative metabolic improvements has not been fully elucidated and may be, in part, independent of weight loss. This suggests that bariatric surgery may improve metabolic comorbidities even in patients who are not morbidly obese. 15
Resolution of Co-morbidities Buchwald et al., JAMA 2004; 292: 1724-37. Predictors contributing to diabetes resolution Changes in Remission Rates of Type 2 Diabetes with Duration of Diabetes 120 Remission (%) 100 80 60 40 20 0 25 25 30 75 75 70 1-2 year (n=20) 3-4 years (n=20) 5-6 years (n=10) 60 40 7-8 years (n=5) 20 80 9-10 years (n=5) 80 20 11-12 years (n=5) 65 65 35 35 13-14 years (n=3) > 15 years (n=3) No Yes Duration Diabetes/ years (n) Hall, Pellen, Sedman & Jain., OBES SURG 2010; 20: 1245-50. 16
Predictors contributing to diabetes resolution Schauer et al., Annals of Surgery 2003; 238: 468-82. End Point (Glycated hemoglobin) Medical Therapy (N=41) Gastric Bypass (N=50) Sleeve Gastrectomy (N=49) P Value Gastric Sleeve Gastric Bypass Bypass vs. Gastrectomy vs. Sleeve Medical vs. Medical Gastrectomy Therapy Therapy 6% - no. (%) 5 (12) 21 (42) 18 (37) 0.002 0.008 0.59 6% with no diabetes medications no. (%) 0 21 (42) 13 (27) <0.001 <0.001 0.10 Baseline - % 8.9 +/- 1.4 9.3 +/-1.4 9.5 +/- 1.7 Month 12 - % 7.5 +/- 1.8 6.4 +/- 0.9 6.6 +/- 1.0 <0.001 0.003 0.23 Body weight Baseline (kg) 104.4 +/- 14.5 Month 12 99.0 +/- 16.4 Change in baseline -5.4 +/- 8.0 106.7 +/- 14.8 77.3 +/- 13.0-29.4 +/- 8.9 100.6 +/- 16.5 75.5 +/ 12.9 <0.001 <0.001 0.50-25.1 +/- 8.5 <0.001 <0.001 0.02 Schauer et al., N Engl J Med 2012; 366: 1567-76. 17
Hormonal Effect of Bariatric Surgery Increases GLP1 Decrease in fasting Ghrelin levels Increase in fasting and post prandial PYY Therefore Bariatric Surgery. Reduces Hunger Improve Satiety Improves Insulin Sensitivity Prevents hepatic production of glucose Predicted Weight Loss RNY Gastric Bypass 70% Excess Weight Loss Sleeve Gastrectomy 60-65% Excess Weight Loss Current Weight Ideal Weight (BMI 24.9) = Excess Weight How to calculate your expected weight loss (EWL) Excess Weight x.70 = Expected Weight Loss How to calculate pts new weight Current Weight EWL = New Weight After Surgery 40 y/o Male 5 10 350 lbs BMI 50.2 350 (CW) 174 (IBW) = 176 (EW).70 % = 123.2 (EWL) Anticipated end weight 226.8 lbs 32.5 18
Nutritional Differences: Bypass Vs. Sleeve Dumping Syndrome: Bypass Only Early dumping or Late dumping The result of poor food choices refined sugars, simple carbohydrates, excess fats, fried foods Symptoms: Sweating, flushing, tachycardia, abdominal fullness, nausea, diarrhea, difficulty concentrating, hunger, fullnes No Dumping with Sleeve Sleeve may worsen GERD Supplementation after Gastric Bypass and Sleeve Gastrectomy Multivitamin and Mineral Supplement Calcium Vitamin B12 Vitamin D 2/day 1500 mg per day 500 mcg daily 3000 international units a day 18 mg of iron, 400 mcg of folic acid, selenium, copper and zinc Calcium citrate preferred 19
Bariatric Surgery Rules of the Tool Eat 3 meals with 1 to 2 snacks daily Consume 70-100 grams protein daily through food and protein shakes Take 30-60 minutes to eat meal Chew food well Focus on eating your meals without distractions Avoid difficult to tolerate textures Avoid high fat and/or high sugar food Avoid simple carbohydrates Use moist cooking methods Take supplements daily Stay hydrated Regular physical activity Rules of the Tool: Know the NO s NO eating and drinking at the same time Separate liquids and solid by 30 minutes No caffeine for 3 months after surgery No carbonations NO NSAIDS NO alcohol for the first year following surgery 20
Questions? 21