Effects of Bariatric Surgery BRITTANY PINKOS

Obesity

Prevalence: about 1/3 or 78.6 million people Highest in non-Hispanic blacks and lowest in non-Hispanic Asians Higher among middle aged adults (40-59)

Co-morbidities: Diabetes Heart disease Stroke Some types of cancer

CDC, 2014

Metabolic Syndrome

Combination of factors that increase likelihood of developing co-morbidities

Diagnosis Criteria- 3 or more Waist Circumference > 40 inches for men, > 35 inches for women Triglycerides > 150 mg/dL HDL < 40 for men, < 50 for women Blood pressure > 130 mm Hg systolic, or > 85 mm Hg diastolic Fasting glucose > 100 mg/dL

American Heart Association, 2014

Bariatric Surgery

15 million people eligible, 1% undergoes surgery Types include restrictive and/or malabsorptive Short and long term benefits and complications

Depends on person

Mechanick, 2013

Types of Bariatric Surgery

Adjustable Gastric Band Least invasive Adjustable, can be removed Restrictive

Sleeve Gastrectomy Removal of part of the stomach Restrictive and malabsorption

Decrease in HCl and intrinsic factor

Hopkinsmedicine.org

Types of Bariatric Surgery

Laparoscopic Roux- en- Y Gastric Bypass Bypasses large part of the stomach and part of the SI

Bypassing duodenum- fat malabsorption Can lead to malabsorption

Biliopancreatic Diversion with Duodenal switch Removes part of the stomach Divides duodenum near pyloric valve, SI divided Combine at common channel

Hopkinsmedicine.org

Which one is best?

Best? Lap band > lap Sleeve > Lap Roux en Y

Terms of wt loss, co-morbidity resolution, complications Early complications (< 30 days) observed <10%, lower in restrictive vs hybrid Biliopancreatic division vs Roux en Y

Greater weight loss and reduction in blood lipids and glucose More long term surgical and nutritional complications

Positively impacts long-term mortality regardless of type Study >8 years

Overall, depends on Individual (Grade D) Piche, 2015JAMA, 2015Mechanick, 2013

Bariatric Surgery in Adolescents

BMI > 35 with comorbidities Type 2 DM, OSA, Non-alcoholic fatty liver disease, Psuedotumor cerebri, CVD,

QOL, Depression, Eating Disorders Risks and outcomes

Short term improvement of depression, eating disorders, QOL Future pregnancy, further research should be done

Nutritional Risks Certain vitamin or mineral deficiencies

Iron, vit. B12, vit. D, Calcium

American Society for Metabolic and Bariatric Surgery

Obesity Algorithm

Helps clinicians to navigate through various steps of treatment in patients overweight/obese

Includes planning options for nutrition strategies exercise prescription behavior modification weight-management medications discussion on surgical options

Asbp.org

Preparation for Bariatric Surgery

Preoperative interventions Consultation Medical Clearance Psych Evaluation Liquid diet 2 weeks prior Smoking cessation

Depends on Insurance provider No evidence to show pre-op intervention programs are effective

Mayoclinic.orgMechanick, 2013

Short Term Complications

Internal Bleeding Infection Blood clots Respiratory issues Leaks from internal incision sites

Hopkinsmedicine.org

Short Term Benefits

Shown to reduce depression up to 3 years Remission of T2DM, cardiovascular issues Weight loss

Booth, 2015

Long Term Complications

Malnutrition Iron and Calcium deficiencies Dumping syndrome Strictures Staple line failure Internal hernias Additional surgeries Failure to lose weight, or weight regain Death

Hopkinsmedicine.org

Long Term Benefits

Remission from T2DM, Cardiac diseases and cancer Decreased prevalence of morbidity

Athropathy, depression, improved QOL, mortality Study publish by JAMA

Significantly lower mortality rates bariatric surgery patients at 3-5 years and 10 years

JAMA 2015

Success of Surgery?

Studies show those in a life-style intervention lost more weight than those continuing usual care prior to surgery

Study shows healthy and stable relationships may support improved long-term outcomes Intervention to improve relationships pre surgery may increase QOL and wt. loss

30% of patients regain weight

Independent factors associated with poor outcomes Age >45, insurance type (Medicare/Medicaid), pulmonary circulatory disease,

RA, CHF, diabetes Booth, 2015ASBP

Relevance to Nutrition and Dietetics

$190.2 billion= cost of obesity 21% of US health care

Surgery cost ~ 20-25K Increasing number of jobs

Increased co-morbidities

Healthycommunitieshealthyfuture.org

New methods of treatment

Maestro System Approved by FDA January 2015 Pace-maker like device Blocks signals along the nerves that connect the stomach to the brain

Reduces hunger, promotes earlier fullness Reduce calorie intake Safe, healthy, durable wt. loss

Contraindications Cirrhosis, portal HTN, esophageal varices, uncorrectable hiatal hernia, planned

MRI, high risk for surgery complications

EnteroMedics, 2015

Enteromedics 2015

American Society of Bariatric Physicians

“It is the position of the ASBP that bariatric surgery is not a quick fix or an easy answer to the obesity epidemic” Surgery is part of a treatment, should not be viewed as the first or only

choice Supports medically-supervised weight loss programs as treatment Effective non-surgical approaches

Structured diet & exercise, behavior modification, medications Does not support FDA’s recommendation to lower BMI requirement for

lap-band surgery Asbp.org

Questions?

References- Journals

Aterburn DE, Olsen MK, Smith VA, Livingston EH, Scoyoc LV, Yancy Jr WS, Eid G, Weidenbacher H, Maciejewski ML. Assocatiation between Bariatric Surgery and Long-term Survival. JAMA. 2015;313(1).

Booth H, Khan O, Prevost AT, Reddy M, Charlton J, Gulliford MC. Impact of bariatric surgery on clinical depression. Interrupted time series study with matched controls. Journal of Affective Disorders. 2015;174:644649.

Clark SM, Saules KK, Schuh LM, Stote J, Creel DB. Assocations between relationship stability, relationship quality, and weight loss outcomes among bariatric surgery patients. Eating Behaviors. 2014: 15(4):670-672

EnteroMedics. Enteromedics announces FDA approval of VBLOC Vagal blocking Therapy for Treatment of Obesity. http://ir.enteromedics.com/releasedetail.cfm?ReleaseID=891316. Accessed April 2015

Kalarchian MA, Marcus MD, Courcoulas AP, Cheng Y, Levinee MD. Peroperative lifestyle intervention in bariatric surgery: intial results from a randomized controlled trial. NCBI. 2013; 21(2):254-260

Mechanick JI, Youdim A, Jones DB, Garvey WT, Hurley DL, McMahon MM, Heinberg LJ, Kushner R, Adams TD, Shikora S, Dixon JB, Brethauer S. Clinical Practice Guidelines for the perioperatice nutritional, metabolic and nonsurgical support of the bariatric surgery patient—2013 update: cosponsorded by American Assocation of Clinical Endocrinologists, The Obesity Society and American Society for Metabolic and Bariatric Surgery. Surgery for Obesity and Related Diseases. 2013; 9:159-191.

Piche ME, Auclair A, Harvey J, Marceau S, Poirier P. How to choose and use Bariatric Surgery in 2015. Canadian Journal of Cardiology. 2015; 31(2):153-166. Roehrig HR, Xanthakos SA, Sweeney J, Zeller MH, Inge TH. Pregnancy after bariactric surgery in adolescents. Obesity surgery. 2007;17(7):873-877. Salahi, L. FDA Panel Recommends Lap Band Expansion: Lap Band Manufacturer Allergan Requests Expansion to Those Less Obese. (ed. Nightline, A.N.) (2010). The JAMA network Journals. Five-year outcomes following bariatric surgery in patients with BMIs of 50 to 60. Science Direct. 2015. Telem DA, Talamini M, Shroyer AL, Yang J, Altieri M, Zhang Q, Gracia G, Pryor AD. Long term mortality rates (>8 year) improve as compared to the general and

obese population following bariatric surgery. Surgical Endoscopy. 2015; 29:529-526.

References- Websites

Hopkins Medicine Laparoscopic adjustable gastric banding. John Hopkins Medicine.

http://www.hopkinsmedicine.org/healthlibrary/test_procedures/gastroenterology/laparoscopic_adjustable_gastric_banding_135,63 /. Accessed May 2015. CDC

Adult obesity facts. Centers for disease control and prevention. http://www.cdc.gov/obesity/data/adult.html. Published September 2014. Accessed May 2015.

American Heart Association About metabolic syndrome. American Heart Assocaition. http://

www.heart.org/HEARTORG/Conditions/More/MetabolicSyndrome/About-Metabolic-Syndrome_UCM_301920_Article.jsp . Published May 2014. Accessed May 2015.

American Society for Metabolic and Bariatric Surgery Position statements. American Society for metabolic and bariatric surgery. http://www.asbp.org/about/positionstatements.html. Published 2015. Accessed

May 2015. Mayo Clinic

Gastric bypass surgery. Mayo Clinic. http://www.mayoclinic.org/tests-procedures/bariatric-surgery/basics/how-you-prepare/prc-20019138. Published April 2014. Accessed May 2015.

Healthycommunitieshealthyfuture.org Economic costs of obesity. National League of Cities. http://www.healthycommunitieshealthyfuture.org/learn-the-facts/economic-costs-of-obesity /.

Accessed May 2015.