What Is Obesity?

1. What Is Obesity? • A life-long, progressive, life-threatening, costly, genetically-related, multi-factorial disease of excess fat storage with multiple co-morbidities ASBS

2. What Is Morbid Obesity? • Clinically severe obesity at which point serious medical conditions occur as a direct result of the obesity • Defined as >200% of ideal weight, >100 lb overweight, or a Body mass index of 40

3. Obesity and Mortality Risk 2.5 2.0 MortalityRatio 1.5 1.0 VeryLow VeryHigh Moderate Low Moderate High 0 20 25 30 35 40 BMI Gray DS. Med Clin North Am. 1989;73(1):1–13.

4. Type II Diabetes Hyperlipidemia Hypertension Cardiac Disease CAD/CHF/LVH Respiratory Disease Sleep apnea Obesity hypoventilation syndrome Degenerative arthritis Depression Pseudotumor cerebri GERD Nephrotic syndrome Pre-eclampsia Infertility Infectious complications Stress incontinence Venous stasis ulcers Hernias Obesity Related Co-Morbidities

5. Medical Co-Morbidities Resolved after Bariatric Surgery Wittgrove AC,Clark GW. Laparoscopic Gastric bypass roux-n-y-500 patients. Obes Surg 2000. And others.

6. Non-Medical Co-Morbidities • Physical • Economic • Psychological • Social

7. Why Surgery? • Diet and exercise are not effective long term in the morbidly obese • Surgery is an accepted and effective approach • Medical co-morbidities are improved/resolved • Surgical risk is acceptable vs. risk of long-term obesity

8. NIH Consensus Conference 1991 • Surgery is an accepted and effective approach that provides consistent, permanent weight loss for morbidly obese patients • Surgery indicated in patients with: • BMI of 40 or over • BMI of 35-40 with significant co-morbidity • documented dietary attempts ineffective

9. Who Is a Surgical Candidate? • Meets NIH criteria • No endocrine cause of obesity • Acceptable operative risk • Understands surgery and risks • Absence of drug or alcohol problem • No uncontrolled psychological conditions • Consensus after bariatric team evaluation: • Surgeon/Dietician/Psychologist/Consultant • Dedicated to life-style change and follow-up

10. Roux-en-Y Gastric Bypass • Combination • Most frequently performed bariatric procedure in the US • First done in 1967 • Laparoscopically since 1993 • 60-70% EBW 14yr follow-up ASBS

11. How Does the Roux-en-Y Work? • Surgery factors: • restriction of meal size • “dumping syndrome” • some malabsorption • decreased appetite • Patient factors: • calorie intake • calorie expenditure

12. Results of Gastric Bypass* • Longest and most thorough follow-up • Significant and durable weight loss • Control of adult onset diabetes mellitus • Control of hypertension • Long term improvement in health and physical functioning *Results achieved in most but not all cases. Degree of improvements vary by individual

13. Laparoscopic Adjustable Gastric Banding • Restrictive • Good results in Europe and Australia • Inamed Lap Band™ FDA approved 6/01 • 40-55% EBW Loss

14. How does the Band work? Surgery Factors: • Restriction of meal size • Decreased appetite Patient Factors: • Decreased calorie intake • Increased calorie expenditure

15. Advantages of Laparoscopy • Fewer wound complications/infection • Decreased rate of incisional hernias • Less pain and faster recovery • Surgeon has better view of the anatomy • Quicker return to work/activities • Shorter hospitalization Nguyen 2001, Wittgrove 2000, Schauer 2000, Watson 1997

16. Hospital Course • Laparoscopic Bypass 2-3 days • Open Bypass 4-7 days • Gastric Band overnight stay Swallow study performed day 1-3 Liquid diet started Home when able to tolerate 3-4 oz/hour

17. Results of Bariatric Surgery • Weight loss • Reduction or improvement in co-morbidities • Increased longevity • Improved Quality of Life • health • social • personal • work

18. Lifetime supplements are necessary to prevent… • Iron Deficiency Anemia • Folate Deficiency • Vitamin B-12 Deficiency

19. Complications of Gastric Bypass • Early complications: • intestinal leakage • acute gastric remnant dilatation • obstruction • cardiopulmonary • MI, PE, pneumonia, atelectasis • Late complications: • anastomotic stricture (5–10%) • anemia, B12 deficiency, Ca deficiency Chapin 1996

20. How are good results achieved? • Follow ASBS recommendations • Surgeon and Hospital commitment • Dedicated bariatric team • Comprehensive care • Lifelong follow up • Database management

21. Weight Loss Program Team • Surgeon • Nurse Practicioner • Bariatric Coordinator • Registered Dietician • Clinical psychologist • Exercise Specialist • Office support staff

22. Will My Insurance Pay for This Procedure? • Each insurance plan has its own provisions and exclusions • Contact your employer and ask if your insurance has coverage for treatment of morbid obesity • What does “coverage” really mean?

23. What Happens if My Insurance Company Denies My Request? • You have the right to appeal • Use supportive documentation from your PCP and surgeon (receipts, programs, gym memberships, ect.)

24. How Long Does it Take to Pre-Authorize My Surgery? • Each insurance company has their own set of rules • They commonly request more information before approving or disapproving • The process takes from 1 hour to 2 weeks, and as long as months

25. What Makes SacramentoBariatric Different? • Integrated program modeled after NIH and ASBS criteria. • Life-long commitment for patient access and follow-up • Multidisciplinary resources for post-surgical needs • Results will be pooled and compared to national data • Internet community and private bulletin boards for patients. • Emphasis on SAFETY and RESULTS!

26. Final Words… * Surgery is only a tool * Patients must commit to lifelong changes in diet and behavior * Think seriously about options * We are here to help