Pete Avara, MD, FACS South Mississippi Surgical Weight Loss Center

Pete Avara, MD, FACS South Mississippi Surgical Weight Loss Center

Obesity Disease State and Prevalence Economic & Medical impact Treatment Options Bariatric Surgery & Advancements in Surgery Safety & Outcomes Addressing Obesity as a PCP Increasing Access

Medical Director, BARInet

Approximately 70% of adults are overweight or obese. 1 17% of children (2-19 years old) are obese. 2 6.3% of adults are morbidly obese (BMI 40). 1 Total medical costs for obesity in 2008 was $147 billion. 3 112,000 obesity-related deaths occur annually. 4 1. National Center for Health Statistics. Health, United States, 2011: With special feature on socioeconomic status and health. 2012. 2. Ogden C, Carroll MD. Prevalence of high body mass index in US children and adolescents, 2007-2008. JAMA 2010; 303(3): 242-249. 3. Finkelstein, EA, Trogdon, JG, Cohen, JW, and Dietz W. Annual medical spending attributable to obesity: Payer- and service-specific estimates. Health Affairs 2009; 28(5): w822-w831. 4. Flegal KM, Graubard BI, Williams DF et al. Excess deaths associated with underweight, overweight, and obesity. JAMA 2005; 293(15):1861-1867.

National Institutes of Health (NIH) recognized obesity as a disease in 1991 American Medical Association (AMA) in 2013 officially recognized obesity as a disease Governmental agencies recognizing obesity as a disease US Internal Revenue Service (IRS) Centers for Medicare & Medicaid Services (CMS) Other organizations supporting surgical treatment of obesity American Heart Association (AHA) American College of Cardiology (ACC) American Diabetes Association (ADA) International Diabetes Federation (IDF)

According to the National Institute of Health Body Mass Index (BMI) is a measure of body fat based on height and weight that applies to both adult men and women Classification BMI Health Risk Normal 18.5-24.9 Overweight BMI Indicators 25.0-29.9 Obesity (class I) 30.0-34.9 Obesity (class II) 35.0-39.9 Extreme Obesity (class III) Mild Moderate Severe 40+ Very Severe NHLBI. Practical Guide: Identification, Evaluation and Treatment of Overweight and Obesity in Adults. October 2000. http://www,nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf

Obesity is a complex, multi-factorial, chronic metabolic disease Obesity involves the following factors: Genetic Metabolic Environmental Physiological Behavioral Psychological American Obesity Association. Fact Sheet: Obesity in the U.S. May 2, 2005. http://www.obesity.org

A contributing factor to obesity is the body s metabolic set point Studies have shown metabolic & bariatric surgery procedures provide a tool to impact the hormonal influence on obesity Sumithran P, Prendergast, LA, Delbridge E, et al. Long-term persistence of hormonal adaptations to weight loss. N Engl J Med. 2011; 365:1597-1604

Obesity is responsible for 2.8 million deaths worldwide annually Obesity accounts for 21% of national health spending Obese individuals have 42% higher annual healthcare costs 77% higher prescription costs (as high as 105%) 37% higher primary care costs Obesity raises annual medical costs per obese individual by $2,741 (in 2005 dollars) Obesity increases lifetime medical costs by 50%

Strong association between Obesity and Diabetes 24 million Americans have Type 2 Diabetes 41% increase in the total costs of treating diabetes was noted from 2007 to 2012 $174 billion to $245 billion

Pulmonary disease obstructive sleep apnea hypoventilation syndrome Nonalcoholic fatty liver disease steatosis steatohepatitis cirrhosis Gallbladder disease Gynecologic abnormalities abnormal menses infertility polycystic ovarian syndrome stress incontinence Osteoarthritis Skin Gout Depression Stroke GERD Cardio/Metabolic Syndrome diabetes dyslipidemia hypertension metabolic syndrome Severe pancreatitis Cancer breast, uterus, cervix, colon, esophagus, pancreas kidney, prostate Phlebitis venous stasis Premature Death

Type II Diabetes Type II diabetes is strongly associated with obesity in all ethnic groups Type II diabetes more than 80% of cases can be attributed to obesity, which may also account for many diabetes related deaths BMI >35 Relative risk increases to 61

Hypertension BP often increased in obese patients Mechanism by which obesity raises BP is poorly understood Weight loss in obese associated with decline in BP For each 1 kg of weight loss, the systolic and diastolic pressure falls by approximately 1mmHg

Heart Failure Important association between obesity and heart failure Risk increased about twofold in obese (BMI >30) Several changes in cardiac function Increases in stroke volume and cardiac output

Decrease life expectancy BMI >30 Increased BMI associated with increased mortality Ischemic heart disease 1.4 Stroke 1.4 Diabetes 2.16

Years of Life Lost 9 8 7 6 5 4 Age 20 Age 30 Age 40 Age 50 3 2 1 0 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 Body Mass Index Christou NV, Sampalis JS, Liberman M, et al. Surgery Decreases Long-Term Mortality, Morbidity, and Health Care Use in Morbidly Obese Patients. Annals of Surgery 2004;240(3):416-424. Fontaine KR, Redden DT, Wang C et al. Years of life lost due to obesity. JAMA 2003; 289:187. Graph represents years of life lost for white women.

SURGERY BMI 35+ with co-morbidities BMI 40+ PHARMACOTHERAPY BMI 27+ with co-morbidities BMI 30+ LIFESTYLE MODIFICATIONS BMI 25+ Adapted from the National Institutes of Health. The practical guide: Identification, evaluation, and treatment of overweight and obesity in adults. 2000; NIH Publication Number 00-4084.

FDA approved drugs: Phentermine, Qsymia, Contrave, Belviq, Saxenda Results: 10 30 lbs. net weight loss Pros: No surgical risks, less expensive, relative safety, may result in improvement in glucose metabolism and T2DM, CAD and Fatty Liver prevention Cons: May be cost prohibitive when not covered by insurance, side effects, not everyone has adequate response, treatment eventually stops.

National Institute of Health (NIH) Consensus (1985,1992) is clear: For the morbidly obese bariatric surgery is the ONLY consistent way to lose more than 100 lbs and keep it off.

Referral (MD/Self) Screening Medical evaluation Treatment decision Lifestyle only Lifestyle combined with pharmacotherapy Surgical treatment Band Bypass Sleeve

Sleeve Gastrectomy Roux en Y Gastric Bypass Adjustable Gastric Band

Pre-op clearance Psychological Evaluation Intensive education Nutrition Exercise Behavioral modification Surgery Post-op Coaching (Interdisciplinary Team) Lifetime follow-up

Physical exam Psychological evaluation Lab work EKG Cardiac Clearance? Sleep study? UGI

In-Hospital mortality rate for bariatric surgery is now 0.1 %* Gallbladder surgery mortality 0.7 %* Hip replacement surgery mortality 0.93%* Data source ASMBS Fact Sheet

Resolution of Obesity-related Medical Problems Type 2 Diabetes 76.8% High blood pressure 61.7% Sleep apnea 83.6% High cholesterol 61.7% Reduction in Mortality Cancer (Breast/Colon) 60% Coronary Artery Disease 56% Type 2 Diabetes 92% Overall Mortality 40% *Source: ASMBS Fact Sheet

Obesity is a chronic disease Consider that treatment for patients with other chronic diseases are not denied coverage based on the cost. Cancer treatment (medical and surgical) Heart surgery

Trends in Coverage - Public Health Insurance: Medicaid/Medicare - Private Health Insurance: Employers/Organizations Nearly two-thirds of health plans sponsored by employers don't cover weight loss surgery. Only 24 states require insurers to cover weight loss surgery for patients. http://www.modernhealthcare.com/article/20140215/info/302159935

Social stigma surrounding Obesity History of catastrophic complication claims In 2013, about 160,000 U.S. patients underwent weight loss surgery roughly the same number as in 2004. That's only about 1% of the estimated 18 million adults who qualify nationwide for the surgery, according to the American Society for Metabolic and Bariatric Surgery.

It is real and limits our ability to help

Bias is an inclination or outlook to present or hold a partial perspective, often accompanied by a refusal to consider the possible merits of alternative points of view. Biases can be learned implicitly within cultural contexts. Prejudice

Weight stigma plays a role in everyday life, including work, school and healthcare settings. It remains a socially acceptable form of prejudice in American society, and is rarely challenged.

Negative perceptions of people affected by obesity exist in employment settings where employees affected by obesity are viewed as less competent, lazy and lacking in self discipline by their co-workers and employers. These attitudes can have a negative impact on wages, promotions and decisions about employment status for employees affected by obesity.

Negative attitudes about individuals with excess weight have been reported by physicians, nurses, dietitians, psychologists and medical students. Research shows that even healthcare professionals who specialize in the treatment of obesity hold negative attitudes.

Even if we admit and examine our prejudices, we may still display their effects.

Non-compliant Dishonest Lazy Lacking in self-control Weak-willed Unintelligent Unsuccessful

47 y/o Female with BP of 189/96 47 y/o with Fasting Glucose of 265 and A1c of 8.4 47 y/o female with anemia and fatigue 47 y/o female with inability to concieve

47 y/o with BMI of 44 and complains she can t get around well

Lung Cancer (smoking) Cirrhosis with GI bleeding (alcohol) HIV, Hepatitis, MVC while intoxicated, abscess from IV drug use, Cardiac valve disease from IV drug use Colon cancer with strong family hx and no screening

22 y/o male shot by old lady during home invasion GSW to aorta and left subclavian artery Officer says he is a bad dude Yes he did well; you could see it coming

36 y/o male, regular patient, hard worker and compliant. You note his weight has increased by 30 lbs over past 2 years. You speak about his weight and he says he is trying to lose.

Yellow Fever Small Pox Bubonic Plague Polio TB HIV Cholera Syphilis

Engage the patient and help them realize this is not just a cosmetic issue Just like smoking cessation, the Doctor has great influence Remember that the patient doesn't want to be obese Patients feel shame and embarrassment about their obesity

Show patients empathy Don t blame or ridicule Don t call them fat Offer some real options

Questions?