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Obesity, Weight Loss and Metabolic SurgeryJim Hewes
UGI and Bariatric Surgeon
Head of service NBT
Aims
• Scale of the problem and costs
• Myths
• Mechanisms behind obesity
• Types of operation and mechanism of action
• Outcomes
• NICE guidance
• Case study
Scale of the problemBMI>25 BMI>30
Scale of the problem
• 34,000 deaths/year attributable to obesity
• 6.8% of all deaths in England
• 9000 premature (before retirement age)*
• Cost to UK economy of overweight and obesity
• £15.8 bn/yr 2007
• £4.2 bn NHS costs**
• T2DM
• 3.2m people (1:20) in UK
• 10% of NHS budget spent on T2DM
• 1:6 hospital beds, 135 amputations per week
• 24,000 preventable deaths per year
* HoC select committee, 2004 **Public Health England
Effects of obesity
Risk factors of obese people developing selected diseases
Risk factors of obese people developing selected diseases
Myths ?
• Obesity is down to poor lifestyle choices driven by will power
• ‘I am thin so why can’t they be’
• ‘No fat people in Ethiopia’
• Surgery expensive method of devolving responsibility for poor behaviour
• Surgery is dangerous and should only be used for extreme cases
• Most patients regret having the operation
• ‘Opens a psychological can of worms’
Prejudice: BBC website comments
‘I have a 21stone relative with a bad heart, and diabetes, who won't diet or exercise or even admit he has a problem. But as he has self induced diabetes he gets free prescriptions. I am 9 stone with rheumatoid arthritis and am penalised by having to pay prescription costs.
He needs therapy not a gastric band. I don't need to pay NI for his sort.’
Prejudice: BBC website comments
‘I have a 21stone relative with a bad heart, and diabetes, who won't diet or exercise or even admit he has a problem. But as he has self induced diabetes he gets free prescriptions. I am 9 stone with rheumatoid arthritis and am penalised by having to pay prescription costs.
He needs therapy not a gastric band. I don't need to pay NI for his sort.’
Prejudice: BBC website comments
‘I have a 21stone relative with a bad heart, and diabetes, who won't diet or exercise or even admit he has a problem. But as he has self induced diabetes he gets free prescriptions. I am 9 stone with rheumatoid arthritis and am penalised by having to pay prescription costs.
He needs therapy not a gastric band. I don't need to pay NI for his sort.’
Prejudice: BBC website comments
‘I have a 21stone relative with a bad heart, and diabetes, who won't diet or exercise or even admit he has a problem. But as he has self induced diabetes he gets free prescriptions. I am 9 stone with rheumatoid arthritis and am penalised by having to pay prescription costs.
He needs therapy not a gastric band. I don't need to pay NI for his sort.’
‘Why is the NHS squandering any of its scarce resources treating self-inflicted illnesses. Let the obese eat themselves to death.’
Prejudice: BBC website comments
‘I have a 21stone relative with a bad heart, and diabetes, who won't diet or exercise or even admit he has a problem. But as he has self induced diabetes he gets free prescriptions. I am 9 stone with rheumatoid arthritis and am penalised by having to pay prescription costs.
He needs therapy not a gastric band. I don't need to pay NI for his sort.’
‘Why is the NHS squandering any of its scarce resources treating self-inflicted illnesses. Let the obese eat themselves to death.’
‘Perfect Storm’ for obesity
• Environmental Changes (obesogenic)
• Altered food supply
• Decreased physical activity
• Stress and distress
• Drugs
• Re-regulate energy balance and increase set point
‘Perfect Storm’ for obesity
• Environmental Changes (obesogenic)
• Altered food supply
• Decreased physical activity
• Stress and distress
• Drugs
• Re-regulate energy balance and set point
Defense of a Set point
• Not ‘will power’
• Disordered energy regulation system
• SET POINT
• Diets don’t work (3-6kg 1 yr)
• Surgery only way to reduce set point
Bariatric Surgery: Adjustable Gastric Band
Roux-en-Y Gastric Bypass
Sleeve Gastrectomy
Mechanisms of action
• Physiological. Changes in:
• Gut hormones
• Neural Signalling
• Intestinal Flora
• Bile acid and lipid metabolism
• Mechanical
• Changes eating behaviours (dumping, taste changes)
Evidence for physiological mechanisms of surgery
• Dramatic effects on hunger and satiety
• Few patients become underweight
• Transient weight gain in pregnancy
• Little weight loss in thin patients
• Changes in endocrine markers
• Ghrelin, PYY, GLP-1, Amylin
• Increased energy expenditure
RYGB is the opposite of Restrictive Dieting
Diet RYGB
Energy Expenditure
Appetite
• Hunger
• Reward based eating
• Satiety
Stress Response
Gut Peptides
• Ghrelin
• GLP-1, PYY, CCK, Amylin
Surgery changes set point
Surgical Outcomes NBSR UK data 2014
• >18,000 patients in 3 years
• 9000 LPGB, 4000 LAGB, 4000 LSG
• In hospital mortality 0.07%
• Complication rate 3%
• Post op stay 2.7 day
• 99% laparoscopic operations
• SAFE and EFFECTIVE despite operating on heavier, older and sicker patients
Safety profile and healthcare usage. KCH (unpublished)
• 700 patients (100/group)
• BS younger
• Highest baseline risk
• No mortality in any group
• No 30d readmissions for BS/MS0
2
4
6
8
10
12
BS GB Hern CR
LOS (d)
BS/MS high safety profile with low healthcare usage
0
2
4
6
8
10
12
14
16
18
BS GB Hern CR
30d Com(%)
0
2
4
6
8
10
12
BS GB Hern CR
Reop (%)
Follow up data
• 1 year
• EWL 58%
• 36% LAGB, 68% LPGB, 58% LSG
• Pre-op functional impairment (64% to 28%)
• OSA 60% off treatment
• 2 years
• 65% of patients with T2DM on no meds
• 3 years
• 59% EWL
Follow up data
• 1 year
• EWL 58%
• 36% LAGB, 68% LPGB, 58% LSG
• Pre-op functional impairment (64% to 28%)
• OSA 60% off treatment
• 2 years
• 65% of patients with T2DM on no meds
• 3 years
• 59% EWL
Improvement of T2DM post surgery
Cost effectiveness of surgery
Cost effectiveness of diabetic surgery
• Savings from drugs alone surgery pays for itself in 2-3 years.
• Not including savings from complications of DM
• Reduction in benefit claims by 75% after 14 months
• £1.45bn increase to GDP due to increased productivity, reduction in health costs and benefits
Cost effectiveness of diabetic surgery
• Savings from drugs alone surgery pays for itself in 2-3 years.
• Not including savings from complications of DM
• Reduction in benefit claims by 75% after 14 months
• £1.45bn increase to GDP due to increased productivity, reduction in health costs and benefits
• Surgery gives better BG control than drugs
• Tariff 2016-
• LPGB: £6271
• LSG/LAGB: £4995
Recent articlesBMJ May 2016Diabetes Care
June 2016
NICE guidelines – update 2014
• BMI >40 or 35-40 with comorbidities
• All non surgical measures tried. Fit for surgery
• Intensive Tier 3 input
• Commitment to long term FU
• Surgery first choice if BMI >50
• BMI >35 recent onset T2DM expedite surgery
• BMI 30-35 with recent onset T2DM consider surgery
• Asian origin consider surgery at lower BMI points
What we offer
Surgery
Non surgical
management
Population wide services
Lifestyle Interventions
Tier 4
NHSE CCG
Tier 3
CCG
Tier 2
Tier 1
Case study
• 48yr male. 186kg, BMI 49
• T2DM (5 yrs)
• HTN, Dyslipidaemia
• OSA on CPAP
• BKA and recurrent cellulitis (RTA)
• Amlodipine, aspirin, furosemide, ramipril, simvastatin, pioglitazone, lantus/novorapid (350u/day, £3k/yr)
• Weight problematic all life. Tried all diets. Yo-yo. Miserable
• Full T3 and T4 assessment
• Lap Gastric Bypass. Discharged D2 well
Weight Loss
80
100
120
140
160
180
200
No
v-1
1
Jan
-12
Mar
-12
May
-12
Jul-
12
Sep
-12
No
v-1
2
Jan
-13
Mar
-13
May
-13
Jul-
13
Sep
-13
No
v-1
3
Jan
-14
Mar
-14
May
-14
Jul-
14
Sep
-14
No
v-1
4
Jan
-15
Mar
-15
May
-15
Jul-
15
Sep
-15
No
v-1
5
Jan
-16
Mar
-16
BYPASS
TIER 3
TIER 4
Post op
• Weight loss 74kg since presentation (BMI 30)
• HbA1C – 37mmol/mol off all diabetic medication (stopped insulin on day of surgery)
• Off CPAP
• On Vitamin and mineral supplementation as per guidelines
• Minimal loose skin, exercising regularly
• ‘Feels like a new man’
• Care transferred back to primary care after 2 yrs
Summary
• Obesity is significant worldwide problem
• Multifactorial aetiology
• Energy balance and set point complex
• Bariatric/Metabolic surgery is
• Safe and effective (clinically and financially)
• Only therapy that has proven long term benefit
• Shift from treating weight to disease
• DM, IIH, OSA, GORD, Infertility, Menorrhagia
• What should we be spending NHS money on?
Any Questions?
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