Surgery’s Role in the Management of Obesity

P A Sufi (MS, FRCS, Lap. Chirurgie)P A Sufi (MS, FRCS, Lap. Chirurgie)Bariatric Surgery LeadBariatric Surgery Lead

North London Obesity Surgery ServiceNorth London Obesity Surgery Service

•The Problem

•The Cause

•Multi-disciplinary Management andRole of Surgery

N

L

O

S

S

A Global Epidemic

N

L

O

S

S

Prevalence of Obesity in UK 2007%

2%

37%

37%

22%

2%

Underweight

Normal

Overweight

Obese

Morbidly obese

http://www.ic.nhs.uk/statistics-and-data-collections/health-and-lifestyles/obesity/statistics-on-obesity-physical-activity-and-diet:-england-february-2009

0

10

20

30

40

50

60

70

80

All Adults Men Women Boys Girls

Normal

Overweight

Obese

Overweight including obese

N

L

O

S

S

Obesity Related Morbidity

Geneticsusceptibility

Autonomicdysfunction

Diet

Atherogenic dyslipidaemia

Obesity

OSA

Physicalinactivity

Pro-thrombotic stateHypertension

Pro-inflammatory state

NASHPCOS

Type II Diabetes

Insulin resistance

IHD

Cirrhosis

CVA

Retinopathy

Nephropathy

OA

Cancer

Cor Pulmonale

Psycho-social

N

L

O

S

SBMI

Pe

rce

nta

ge

20 25 30 35 40

15

10

20

25

30

Impact of Obesity on GP Consultations

Brown WJ et al. Int J Obes 1998;22:520-528.

N

L

O

S

S

Impact of Obesity on HRQL

Quality of Life in the Obese

0

20

40

60

80

100

Physica

l fun

ction

Role-p

hysica

l

Bodily

pain

Gen

eral

Health

Vitality

Socia

l fun

ctionin

g

Role-e

mot

iona

l

Men

tal h

ealth

Physica

l com

pone

nt

Men

tal c

ompon

ent

HRQL

Sco

re Normal weight

Morbidly obese

Larsson U et al. International Journal of Obesity (2002) 26, 417 – 424.

N

L

O

S

S

Obese Die Early

http://www.ic.nhs.uk/statistics-and-data-collections/health-and-lifestyles/obesity/statistics-on-obesity-physical-activity-and-diet:-england-february-2009

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

Normal

Overweight including obese

Morbidly obese

Normal 37.7 61.8 48.9 34.3 30.9 26.1 26.4 29.5

Overweight including obese 60.8 32.9 49.3 64.8 68.4 73.5 73.0 69.0

Morbidly obese 1.8 0.8 1.4 2.5 2.1 2.1 1.7 0.8

All

ages16-24 25-34 35-44 45-54 55-64 65-74 75+

N

L

O

S

S

Changes in Calorie Consumption and Use

http://www.grida.no/publications/rr/food-crisis/page/3560.aspx

Kcal/week: 1950s

300(with duvet)

575(with blankets)

Making a bedMaking a bed

(50%(50%))

Almost zero(lighting a gas fire)

1300(making a coal fire)

Heating (100%Heating (100%))

270(by machine)

1500(by hand)

WashingWashing

clothes (80%clothes (80%))

276(driving)

2400(on foot)

GroceryGroceryshoppingshopping

(90%(90%))

Kcal/week: 2000sActivity

http://nationalobesityforum.org.uk/images/stories/PDF_training_resource/in-depth-background.pdf

N

L

O

S

S

Average Calorie Requirement

1,9402,550Adults

2,1102,75515–18

1,8452,22011–14

1,7401,9707–10

1,5451,7154–6

1,1651,2301–3

GirlsBoys

Calories per dayAge (yr) Small biscuit (50 cal) ≈ 10 min walk

Large cookie (250 cal) ≈ 50 min walk

A doughnut (300 cal) ≈ 60 min walk

A fast food "meal" (1500 cal) ≈ 5 hr walkrunning at a 10 min/mile pace for 2½ hours

≈ BMR +/- 60 min walk

One tsp sugar (20cal) ≈ 4 min walk

One can coke (160cal) ≈ 30 min walk

N

L

O

S

S

Obesity Care Pathways

N

L

O

S

S

Care Pathway – Primary Care

•Assess weight and evaluate, exclude endocrine cause

•Discuss obesity and provide information

•Recommend healthy lifestyle, supervised diet, medication etc

•Manage co-morbidity: blood sugar, serum lipids, hypertension

•Revaluate and repeat if necessary

•Refer for bariatric surgery

N

L

O

S

S

Prevalence of Adult Obesity

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

Year

%Normal

Overweight

Obese

Morbidly obese

Overweight & obese

Normal 45.5 45.2 43.7 42.2 41.6 40.6 40.4 38.6 37.0 37.7 37.8 36.7 37.9 36.8 37.7

Overweight 38.0 37.4 38.1 38.7 38.5 38.3 38.0 38.8 39.2 38.1 37.9 38.8 37.3 37.6 36.7

Obese 14.9 15.7 16.4 17.5 18.4 19.4 20.0 21.2 22.4 22.5 22.6 22.9 23.2 23.9 24.0

Morbidly obese 0.8 1.0 0.9 0.9 1.6 1.3 1.4 1.5 1.7 1.8 1.9 1.7 1.8 2.1 1.8

Overweight & obese 52.9 53.1 54.5 56.2 56.9 57.7 57.9 60.0 61.6 60.6 60.5 61.8 60.5 61.6 60.8

199

3

199

4

199

5

199

6

199

7

199

8

199

9

200

0

200

1

200

2

200

3

200

4

200

5

200

6

200

7

N

L

O

S

S

Prevalence of Obesity in Children

http://www.iotf.org/childhood/

http://www.ic.nhs.uk/pubs/opadjan08

Obesity Prevalence 2007

0

10

20

30

40

50

60

70

80

Gender

Perc

en

tag

eNormal

Overweight

Obese

Normal 69 70

Overweight 14 14

Obese 17 16

Boys Girls

N

L

O

S

S

Effect of Diet and Surgery on Weight

•Diet & exercise effective up to 6m

•60% failure at 1 yr

•80% failure at 2 yrs

•100% failure at 5 yrs

•Surgery effective indefinitely

Changes In Energy Expenditure Resulting From Altered BodyWeighthttp://content.nejm.org/cgi/reprint/332/10/621.pdf

Is the Energy Homeostasis System Inherently Biased TowardWeight Gainhttp://diabetes.diabetesjournals.org/content/52/2/232.full.pdf+html

Pyruvate and Satiety: Can We Fool the Brain?http://endo.endojournals.org/cgi/reprint/146/1/1.pdf

N

L

O

S

S

NICE Guideline (CG43 - 2006)

Bariatric surgery is recommended asBariatric surgery is recommended as a treatment optiona treatment option for adultsfor adultswith obesity ifwith obesity if all of the following criteriaall of the following criteria are fulfilled:are fulfilled:

BMIBMI 40 kg/m40 kg/m22 or moreor more, or, or between 35between 35 -- 40 kg/m40 kg/m22 andand otherothersignificant diseasesignificant disease (for example, type 2 diabetes or high blood(for example, type 2 diabetes or high bloodpressure) that could be improved if they lost weightpressure) that could be improved if they lost weight

all appropriateall appropriate nonnon--surgical measures have failedsurgical measures have failed to achieve or maintainto achieve or maintainadequate, clinically beneficial weight loss for at leastadequate, clinically beneficial weight loss for at least 6 months6 months

the person has been receiving or will receive intensive managemethe person has been receiving or will receive intensive management in ant in aspecialist obesity servicespecialist obesity service

the person isthe person is generally fitgenerally fit for anaesthesia and surgeryfor anaesthesia and surgery

the personthe person commits to the need for longcommits to the need for long--term followterm follow--upup..

Bariatric surgery is also recommended asBariatric surgery is also recommended as a firsta first--line optionline option(instead of lifestyle interventions or drug treatment) for adult(instead of lifestyle interventions or drug treatment) for adults with as with aBMI of more than 50 kg/mBMI of more than 50 kg/m22 in whom surgical intervention isin whom surgical intervention isconsidered appropriate.considered appropriate.

N

L

O

S

S

Childhood Obesity – NICE 2006 Bariatric surgery should be considered only if child is

morbidly obese (BMIBMI≥≥ 4040).

achieved or nearly achieved physiological maturitymaturity / attained majority ofskeletal maturity (13 yrs for girls and 15 yrs for boys).

have obesity related coco--morbiditiesmorbidities remediable with weight loss and

if 6 months6 months of supervised weight loss attempts fail

http://adc.bmj.com/cgi/content/full/93/5/369

N

L

O

S

S

Obesity Surgical Procedures:

AGB BPDRY Gastric bypass

VBG JIB BPDDS

N

L

O

S

S

Who will benefit from Bariatric Surgery ?

AdultsAdults

90%90% -- 95% of BMI of95% of BMI of 35 kg/m35 kg/m22 with cowith co--morbidities or BMImorbidities or BMI 40 kg/m40 kg/m22

unlikely to achieve or maintain clinically beneficial weight losunlikely to achieve or maintain clinically beneficial weight loss through nons through non--surgical means.surgical means.

For Asian ethnicity, the referral criteria should be 3 BMI pointFor Asian ethnicity, the referral criteria should be 3 BMI points less!s less!

In England, 390,000 people (0.8%), have BMI 35In England, 390,000 people (0.8%), have BMI 35--39.9 kg/m39.9 kg/m22 with at leastwith at leastone coone co--morbidity:morbidity:

•• Type II diabetes mellitusType II diabetes mellitus

•• Hypertension, Cardiomyopathy, IHD and CVAHypertension, Cardiomyopathy, IHD and CVA

•• Obstructive sleep apnoea, Pulmonary hypertensionObstructive sleep apnoea, Pulmonary hypertension

•• OsteoarthritisOsteoarthritis

Failure of conservative measures beyond 6 months.Failure of conservative measures beyond 6 months.

AdolescentsAdolescents

BMIBMI 40 kg/m40 kg/m22

Failure of conservative measures beyond 6 monthsFailure of conservative measures beyond 6 months

http://www.nice.org.uk/usingguidance/commissioningguides/bariatric/determininglocalservicelevels/Assumptions.jsp

N

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O

S

S

Beneficial Effects of Adequate Surgery

• 40% reduction in all cause mortality- 37.6 v 57.1 deaths/10,000 person years (P<0.001)- 56% reduction CVD death- 92% reduction in diabetes death

- 60% reduction in cancer death

• 50-85% EBWL maintained in 80% ≥ 8-years• 60-80% remission of diabetes II• 40-60% remission or improvement of hypertension• 100% remission of sleep apnoea• Improvement in

- Serum cholesterol levels- Risks of IHD- Metabolic syndrome- Osteoarthritis etc.

• Reduce the risks for gestational diabetes, hypertension,DVT, stress incontinence, preeclampsia, cephalopelvicdisproportion, macrosomia, and caesarean delivery

Sjöström et al. 2007. NEJM

Adams et al. 2007. NEJM ;357:8