60% (34 million) of Americans are overweight

1. Riverside Medical and Surgical Weight Loss CenterDavid Salzberg, M.D., Bariatric SurgeonFelice Haake, D.O., Medical Bariatrician757-637-7637

2. 60% (34 million) of Americans are overweight

3. 25% of American children are overweight

4. 6% of health care expenditures ($238 billion / year)

5. Obesity Trends* Among U.S. AdultsBRFSS, 1985 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

6. Obesity Trends* Among U.S. AdultsBRFSS, 1992 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

7. Obesity Trends* Among U.S. AdultsBRFSS, 1999 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

8. Obesity Trends* Among U.S. AdultsBRFSS, 2006 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

9. Obesity Trends* Among U.S. AdultsBRFSS, 2009 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

10. Economic….. • National cost = $200 billion $93 Billion in medical bills $33 Billion on weight-loss products $74 Billion in “Absenteeism”

11. The Personal Cost of Obesity • Change in the cost of living after • weight-loss surgery can be dramatic References: 1. Health Management Research Center, University of Michigan, 2001; 2. U.S. Bureau of Labor Statistics, Consumer Expenditures in 2001; 3. Source: Colditz, GA. “Economic costs of obesity and inactivity,” Med Science Sports Exercise, 1999; 4. Marketdata Enterprises, Inc., 10/02; 5. U.S. Bureau of Labor Statistics, Consumer Expenditures in 2001

12. 300,000 deaths annually

13. Prevalence of Medical Co-Morbidities Attributable to Obesity

14. Relative Risk of Cancer - Men

15. Relative Risk of Cancer- Women

17. A typical fast food meal • Big Mac:570 kcal • Large Fries: 540 kcal • 32 0z (large) soda: 400 kcal TOTAL 1510 kcal A 70 kg moderately active man requires 2100 kcal/day (3 meals).

18. Where Do Patients Fit In? Clinical Terms Used to Describe Various Levels of Body Fat Normal Weight(BMI 18.5 to 24.9) Overweight(BMI 25 to 29.9) Obese(BMI 30 to 34.9) Severely Obese(BMI 35 to 39.9 ) Morbidly Obese(BMI 40 or more)

19. Weight Loss at RRMC • Medical • Surgical • Behavioral

20. Weight Loss Options (Moderately Overweight) Medical Treatment of Obesity • Diet • low in calories, fat and carbohydrates • Exercise • 40 minutes 5 times per week • Behavior Modification • eat 3 sensible meals per day, avoid snacking, meal replacement

21. Two Options Accelerated Weight Loss • The use of pre-packaged meal replacements and supplements to achieve fast results. Lean&Clean • A whole foods approach to weight loss and lifelong health.

22. Where Do Patients Fit In? Clinical Terms Used to Describe Various Levels of Body Fat Normal Weight(BMI 18.5 to 24.9) Overweight(BMI 25 to 29.9) Obese(BMI 30 to 34.9) Severely Obese(BMI 35 to 39.9 ) Morbidly Obese(BMI 40 or more)

23. Challenge with Medical Therapy

24. Problems with Conservative WL in Morbidly Obese • Most patients (95-97%) regain most or all of the weight that was lost within 1 year following diet or drug treatment • The average amount of weight loss is relatively small -- 10-40 pounds • Drug therapy may be associated with severe complications (Fen-Phen and heart disease)

25. Weight Loss Surgery • Average 55% loss of excess body weight OVER LIFETIME

26. Surgery for morbid obesity? Why? • Calories OUT must be > Calories IN • Restrict • Malabsorb

27. Most Common Surgical Options Gastric Bypass (GBP) Sleeve Gastrectomy Band System Restrictive and Malabsorptive Restrictive Restrictive and Adjustable

28. Gastric Bypass (Roux-en-Y)(43644)

29. LAGB Procedure (43770)

30. Sleeve Gastrectomy (43775)

31. Bariatric Patients at RRMC

32. Preop Workup • Information Session (Free, group or private) • Initial Bariatric Consultation (Level 5 Visit) • Labs and Imaging • Forward to Insurance Carrier

33. Candidacy? • BMI criteria • BMI is at least 40 • BMI is at least 35 and with combormidities • Are at least 18 years old • Understand surgery and the risks • No uncontrolled psychological conditions • Are prepared to attend regular follow-up sessions and make lifestyle changes • Consensus of the bariatric team

34. Insurance • Varies by insurance company • Varies by patients choice of plan • Many large corporations on Peninsula offer coverage • Center employs coordinator/insurance specialist who will assist

35. Insurance Approval • This is often the biggest delay! • Requirements and lead time vary by company • Sufficient documentation of medically supervised diet

36. Finance Programs • Credit Lines through Riverside

37. RMWLC Requirements • Helpful to have all paperwork regarding past weight loss attempts from PCP • Initial questionnaire

38. Patient Flow- Inpatient • To Operating Room • Walking night of surgery • Drinking day after surgery • Home POD 2 • Back to work in less than two weeks

39. Possible Risks and Complications Remember: There are risks associated with any surgery. Sources: Ren CJ, Laker S, Weiner M, Hajoseuedjavadi O, J Am Coll Surg, v 202, No 2, Feb 2006; ASERNIPS Executive Summary, 2002.

40. Mortality Mortality Rate 2.00 1.50 Rate (%) 1.00 0.50 0.00 Flum1 DeMaria2 Hernia4 HHS4 Buckwald3 Carotid Stent4 CABG w/ cath4 GI Obstruction4 Appendectomy4 Lap Cholecystectomy4 Drug Eluding Stent4

41. Comparing Weight-Loss Results Gastric Bypass LAP-BAND Source: O’Brien et al. Obesity is a Surgical Disease: Overview of Obesity and Bariatric Surgery, ANZ J Surg, 2004; 74: 200-204.

42. % Medical Co-Morbidities Resolved after Bariatric Surgery

43. Riverside Medical & Surgical Weight Loss Center • Full service metabolic center, under one roof • Choice of Medical or Surgical options • Dietician, Exercise, Behavioral • Access to diagnostics in same building • Open, Active correspondence with referring provider 757-637-7637