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It’s Time to Act on Obesity:
When Bariatric Surgery Is
the Right Choice
Presented by: [Surgeon’s Name]
A Presentation for
Health Care Professionals
Treating Obesity
This presentation is intended to provide health care
professionals with information on obesity and the bariatric
surgery treatment option. It is brought to you by Ethicon
and is not certified for continuing medical education.
2
Presentation topics
• Obesity: An Epidemic
• Considering Bariatric Surgery
• Identifying Bariatric Surgery Candidates
• Understanding the Surgical Options
• Patient and Physician Resources
• An Important Partnership
3
Obesity: An Epidemic
4
The importance of more aggressive treatment
• Obesity is a national disease epidemic1,2
• Obesity is a contributing factor to:
–
Many serious health conditions and
diseases3
–
Decreased quality of life4
–
Mortality5,6
Figure may require
permission.
• Obesity can affect every major organ
system in the body.7
• Obesity is associated with a 50% to
100% increased risk of death from all
causes compared to normal-weight8
• Only ~20% of overweight individuals
who attempt to lose weight are
successful9
Prevalence† of Self-Reported Obesity Among
US Adults by State and Territory in 2014
*
Sample size <50 or the relative standard error (dividing the
standard error by the prevalence) ≥30%.
• The costs to the patient and society are
high10
Prevalence estimates reflect Behavioral Risk Factor Surveillance System (BRFSS) methodological changes started in 2011. These prevalence
†
estimates should not be compared with estimates before 2011.
1. Ogden CL, et al. NCHS Data Brief. 2012;(82):1-8. 2. Centers for Disease Control and Prevention. Obesity prevalence maps.
http://www.cdc.gov/obesity/data/prevalence-maps.html. Updated September 11, 2015. Accessed September 23, 2015. 3. Stommel M, et al.
Obesity (Silver Spring). 2010;18(9):1821-1826. 4. Guyenet SJ, et al. J Clin Endocrinol Metab. 2012;97(3):745-755. 5. Allison DB, et al. JAMA.
1999; 282(16):1530-1538. 6. Fontaine KR, et al. JAMA. 2003;289(2):187-193.7. Buchwald H. Consensus Conference Statement: Bariatric surgery
for morbid obesity: Health implications for patients, health professionals, and third-party payers. ASMBS. Surg Obes Rel Dis. 2004; 1: 371-381. 8.
ASMBS. (2013). Fact sheet : Obesity in America. Gainesville, FL: Amber Hamilton. 9. Wing RR, et al. Am J Clin Nutr. 2005;82(suppl 1):222S225S. 10. Cawley J, et al. J Health Econ. 2012;31(1):219-230
5
The consequences of being severely obese are
significant
• As BMI increases, so does the risk of obesity-related conditions and mortality3,5,6
• Obesity and overweight together are the second leading cause of preventable
death in the US, accounting for 300,000 deaths per year.
Prevalence of Significant Morbidities Per Weight3
60%
Years of Life Lost3
20
49%
50%
45%
15
13
40%
29%
30%
22%
17%
20%
10%
10
8
23%
19%
19%
12%
8%
8%
5
5
4%
1
0%
0
Diabetes
BMI 25
Hypertension
BMI 30
BMI 40
Arthritis
BMI 40+
BMI 25
BMI 35
BMI 40
BMI 40+
BMI=body mass index.
3. Stommel M, et al. Obesity (Silver Spring). 2010;18(9):1821-1826. 5. Allison DB, et al. JAMA. 1999;282(16):1530-1538.
6. Fontaine KR, et al. JAMA. 2003;289(2):187-193.
6
Obesity poses an economic burden
to the individual and to society
US annual medical cost of obesity
(estimated to be $3115 per person)
20.6%
$168 billion11*
of national health expenditures are spent
treating obesity-related illness10
80%
Up to 30%
greater medical costs for patients
with obesity than for normalweight individuals12
higher prescription drug
spending for patients with
obesity than for normal-weight
individuals13
*
2008 dollars.
11. Kaplan LM, et al. Bariatric Times. 2012;9(5):12-13. 10. Cawley J, et al. J Health Econ. 2012;31(1):219-230. 12. Withrow D, et al.
Obes Rev. 2011;12(2):131-141. 13. Finkelstein EA, et al. Health Aff (Millwood). 2009;28(5):w822-w831.
7
Considering Bariatric Surgery
8
What is unique about bariatric surgery?
Bariatric surgery:
• Has a unique mode of action that allows
for metabolic change versus caloric
restriction, as with dieting11
• Has the greatest weight loss results of any
treatment option11
• Has the longest weight loss duration of
any treatment option11
A 200-pound
patient fighting
obesity with diet
and exercise alone
would only be able
to achieve a
sustained weight
loss of
4 pounds over
20 years16
• Has the ability to reduce or resolve obesityrelated conditions, risks,11 and the need for
supplemental medicines14
• Has been shown to significantly improve
quality of life15
• May reduce the risk of mortality15
11. Kaplan LM, et al. Bariatr Times. 2012;9(9 suppl C):C12-C13. 14. Schauer PR, et al. N Engl J Med.
2012;366(17):1567-1576. 15 Sjöström L, et al. JAMA. 2012;307(1):56-65. 16. Calle EE, et al.
N Engl J Med. 2003;348(17):1625-1638.
9
Physiologic changes induced by bariatric surgery17
Some surgical procedures can uniquely interrupt the metabolic dysregulation cycle17-20
• Stapling procedures (sleeve
gastrectomy and gastric
bypass)21:
–
–
–
Alter the gut hormonal
signaling system that affects
hunger, satiety, and
metabolism
Alter signaling processes in
a way that supports weight
loss
Restricts the stomach to
reduce calorie intake
• Gastric banding22:
–
Restricts the stomach to
reduce calorie intake
17. Chambers AP, et al. Gastroenterology. 2011;141(3):950-958. 18. Shin AC, et al. Endocrinology. 2010;151(4):1588-1597. 19.
Peterli R, et al. Ann Surg. 2009;250(2):234-241. 20. Stylopoulos N, et al. Obesity (Silver Spring). 2009;17(10):1839-1847. 21.
Brethauer SA. Surg Clin North Am. 2011;91(6):1265-1279. 22. McBride CL, et al. Surg Clin North Am. 2011;91(6):1239-1247.
10
Bariatric surgery results
• Bariatric surgery is currently the most effective long-term treatment for obesity11
• Some weight regain is normal23
• Benefits of weight loss and alleviation of obesity-related conditions (even if just for short
term) still result in healthier lifestyle23
Treatment
Average Weight
Loss at 3 Years
Average Weight
Loss at 5 Years
Diet and exercise
-0.1%24
-1.6%24
10.7%25,*
Not enough data
Average Weight
Loss at 3 Years
Average Weight
Loss at 5 Years
Gastric bypass
71.2%26
60.5%27
Sleeve
gastrectomy
66.0%28
49.0%27
Gastric banding
55.2%26
29.5%27
Drug therapy
Surgery
* This value represents follow-up of 108 weeks.
11. Kaplan LM, et al. Bariatr Times. 2012;9(9 suppl C):C12-C13. 23. Arterburn DE, et al. Obes Surg. 2013;23(1):93-102. 24. Sjöström
L, et al. N Engl J Med. 2004;351(26):2683-2693. 25. Garvey WT, et al. Am J Clin Nutr. 2012;95(2):297-308. 26. Garb J, et al. Obes
Surg. 2009;19(10):1447-1455. 27. Brethauer SA, et al. Ann Surg. 2013;258(4):628-636. 28. Himpens J, et al. Obes Surg.
2006;16(11):1450-1456.
11
Identifying Bariatric Surgery Candidates
12
Ensuring that obesity gets diagnosed and treated •
Many individuals don’t realize that they have obesity
because of the high number of overweight Americans
around them. Utilizing BMI data, it needs to be
specifically diagnosed with the disease of obesity.
•
Discussing obesity with a patient must be done in a
sensitive way.
•
Begin the conversation about weight and how it affects their health
•
Assess the patients efforts to date and readiness to take action
•
Practice active listening to their concerns and experiences
•
Focus on the disease of obesity and how to treat it versus how they got
there
•
Provide helpful information on what treatment options can deliver
•
Discuss support that they have or will need.
13
Society treatment guidelines
• Many major medical societies have recognized obesity as a disease and
included it in treatment guidelines for excess weight or obesity-related disease
reduction or resolution
American Heart
Association,
American College of
Cardiology,
The Obesity Society
(AHA/ACC/TOS)
National Heart, Lung and
Blood Institute,
National Institute of
Health
(NHLBI/NIH)
American Association of
Clinical Endocrinologists.
American College of
Endocrinology
(AACE/ACE)
Guidelines
for:
Cardiac Issues and Obesity
Obesity
Type 2 Diabetes and Obesity
Bariatric
Surgery
Intervention
Adults BMI > 40 or BMI > 35
with obesity-related comorbid
conditions if did not respond
to behavior treatment with or
without pharmacotherapy
Patients with clinically
severe obesity (BMI ≥ 40 or
a BMI ≥35 with comorbid
conditions) when less
invasive methods of weight
loss have failed and the
patient is at high risk for
obesity-associated morbidity
or mortality
BMI > 35 with comorbidities,
adjustable gastric band,
gastric sleeve, gastric bypass
BMI > 30 with comorbidities,
adjustable gastric band
BMI=Body mass index.
14
Surgical treatment of patients
with obesity29
Who is eligible for surgery?
Patients who:
• Have a BMI ≥40 kg/m2 or a BMI ≥35 kg/m2
with obesity-related conditions,* such as30:
– Type 2 diabetes mellitus
– Cardiovascular conditions
– Sleep apnea
– Fertility-related complications
– Orthopedic conditions
– Cancer
• Are experiencing obesity-related quality-of-life issues
Migraines
Depression
Obstructive
sleep apnea
High cholesterol
Hypertension
Asthma
GERD
Type 2 diabetes
Urinary stress
incontinence
Polycystic ovarian
syndrome
Osteoarthritis or
joint disease
Venous stasis
disease
• Have attempted to lose weight using nonsurgical
methods but have not succeeded
*
Of note, there are >40 documented obesity-related conditions.
BMI=body mass index; GERD=gastroesophageal reflux disease.
29. The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Bethesda, MD: National Heart,
Lung, and Blood Institute; 2000. NIH publication 00-4084. https://www.nhlbi.nih.gov/files/docs/guidelines/prctgd_c.pdf. Accessed
September 8, 2015. 30. Obesity in America. American Society for Metabolic and Bariatric Surgery Web site.
https://asmbs.org/resources/obesity-in-america. November 2013. Accessed October 16, 2015.
15
Bariatric surgery is a life-changing event
Patients should:
• Be willing to commit to following dietary
restrictions, adhering to an exercise
program, taking dietary supplements, and
complying with follow-up recommendations
• Be well informed and highly motivated
• Have a supportive family or social
environment
• Stay away from smoking or drinking
alcohol
• Be actively treating severe depression or
other mental disease
16
Understanding the Surgical Options
17
Most common bariatric procedures
Roux-en-Y
Gastric Bypass31
Bypass a portion of
the small intestine and
create a 15- to 30-cc
stomach pouch
Sleeve
Gastrectomy32
Resect approximately
three-fourths of
the stomach
Laparoscopic
Biliopancreatic
Adjustable
Diversion
22
Gastric Banding (± Duodenal Switch)33
Place implantable
device around the
uppermost part of the
stomach
Remove part of the
small intestine;
performed with or
without duodenal
switch
Less than 2 years after surgery; however, no statistically significant difference between assessments made at ≤2 years and >2 years;
At least 3 years after surgery.
31. Powell MS, et al. Surg Clin North Am. 2011;91(6):1203-1224. 32. Brethauer SA. Surg Clin North Am. 2011;91(6):1265-1279. 22. McBride CL, et al.
Surg Clin North Am. 2011;91(6):1239-1247. 33. Brethauer S, et al. In: Carey WD, ed. Current Clinical Medicine. 2nd ed. Philadelphia, PA: Saunders
Elsevier; 2010:391-396.
*
†
18
Most common bariatric procedures
Treatment
Excess
Weight Loss
How the procedure works
Metabolic
changes
Restriction




Roux-en-Y Gastric
Bypass
~62%35,*
Sleeve Gastrectomy
66%36,†
Biliopancreatic Diversion
(± Duodenal Switch)
~70%37


Laparoscopic Adjustable
Gastric Banding
55%36,†
X

Less than 2 years after surgery; however, no statistically significant difference between assessments made at ≤2 years and >2 years;
At least 3 years after surgery.
35. O’Brien PE, et al. Obes Surg. 2006;16(8):1032-1040. 36. Shi X, et al. Obes Surg. 2010;20(8):1171-1177. 37. Ionut V, et al. J
Diabetes Sci Technol. 2011;5(5):1263-1282.
*
†
19
Disease
resolution
20
Tools to consider surgical results
• Utilize the online Bariatric Surgery
Comparison Tool
– Considers a patient’s height, weight, and
obesity-related conditions to provide
potential outcomes of bariatric surgery
based on the experiences of more than
75,000 patients in the United States38
– Can compare potential results between
procedures, or versus patients
personal experience with non-surgical
treatment options.
• Order brochures, posters, body mass index
cards, and videos that may be helpful for
patients
• Patients information site at REALIZE.com
• HCP information site at ethicon.com/obesity
38. Benoit SC, et al. Obes Surg. 2014;24(6):936-943.
21
Safety profile for bariatric surgery
• Clinical evidence shows that the risks associated with morbid obesity
outweigh the risks associated with metabolic and bariatric surgery39,†
• Most procedures (>90%) are performed laparoscopically40 due to significant
advancements in laparoscopic technique41
• Accreditation by the American Society for Metabolic and Bariatric Surgery has
resulted in standardization of skills42
Procedure
Bariatric
surgeries ‡
Other
common
procedures‡
Complications
Mortality
Gastric bypass
0.4%
0.2%
Gastric banding
*
*
Colectomy
2.4%
0.8%
Hysterectomy
0.4%
*
Cholecystectomy
0.9%
0.9%
Hip replacement
1.0%
0.2%
2010 data; * ≤10 cases reported; ‡ Washington State Health Care Authority Heath Technology Assessment. Bariatric Surgery Draft
Key Questions: Comment & Response. 2014.
http://www.hca.wa.gov/hta/Documents/bariatric_key_qs_comments_response_110714.pdf Last accessed 12/11/2015.
39. Direct Research, LLC, Center for Medicare and Medicaid Services. FY 2010 MedPAR. Medicare Fee-for-Service Inpatient
Discharges with Selected Procedures. 40. Seki Y, et al. Surg Technol Int. 2010;20:139-144. 41. Reoch J, et al. Arch Surg.
2011;146(11):1314-1322. 42. Gould J, et al. J Am Coll Surg. 2011;213(6):771-777.
†
22
Bariatric surgery: benefits vs risks
Benefits of bariatric surgery may include:
• Highest level of excess weight loss39
• Strongest obesity-related condition resolution or
reduction39
• Reduction in risk of conditions such as cancer15
• Improvement in fertility48
• Improvement in quality of life14
• Reduction in mortality39
• Reduction in patient health care utilization/direct
and indirect costs44
Risks39*
• Band erosion/slippage/leak/malfunction†
• Esophageal spasm/reflux or esophageal/stomach
inflammation
• Gastric perforation
• Outlet obstruction
*
List is not exhaustive. Risks are in addition to the general risks of surgery. Patient weight, age, and medical history play a significant
role in determining specific risks; † Associated with laparoscopic adjustable gastric banding.
39. Direct Research, LLC, Center for Medicare and Medicaid Services. FY 2010 MedPAR. Medicare Fee-for-Service Inpatient
Discharges with Selected Procedures. 15. Sjöström L, et al. JAMA. 2012;307(1):56-65. 43. Merhi ZO. Fertil Steril. 2009;92(5):15011508. 14. Schauer PR, et al. N Engl J Med. 2012;366(17):1567-1576. 44 Holtorf AP, et al. In: Huang CK, ed. Advanced Bariatric and
Metabolic Surgery. Rijeka, Croatia: InTech; 2012:61-86.
23
Referral considerations
Requirements for approval depend on the insurance policy.
Most policies require:
• Documented history of medical weight loss attempts (3–6 months)
• 5-year weight history and medical records
• Psychological evaluation
• Nutrition counseling
A referral for a bariatric surgery
consultation is similar to any
other specialist referral. The
surgeon will examine the patient
and determine if surgery is the
best option.
24
Postoperative management
• Surgery is a tool to help patients lose weight
and help keep it off. Diet and exercise are an
essential part of the new routine
• Recovery takes time and patience
• Amount and timing of weight loss will vary
• Patients may experience discomfort and pain
as their body heals
• Diet restrictions should be strict
• Additional nutrition screening/supplementation
may be required
• Medication adjustments may be needed
• Length of time to return to normal activities varies
• Patients who undergo laparoscopic adjustable gastric banding will require
ongoing appointments to assess band restrictiveness and make adjustments
25
Patient and Physician Resources
26
Patient and physician resources
• The Obesity Society (TOS)
• Strategies to Overcome and Prevent (STOP) Obesity Alliance
• Obesity Action Coalition (OAC)
• Obesity Action Coalition (OAC)
• American Society for Metabolic
and Bariatric Surgery (ASMBS)
• Ethicon.com/obesity (for HCPs)
–
Find HCP information and resources
–
Find a surgeon
–
Download/order materials
• Realize.com/obesity (for patients)
–
Find a surgeon, find a seminar
–
Obtain general information
–
Use the surgery comparison tool
• A local Bariatric Surgeon
HCPs=health care professionals.
27
An Important Partnership
28
Patient, HCP and surgeon partnership is important
• It is essential for the patient, primary healthcare professional or specialist
and bariatric surgeon to work together to identify the best treatment for
the patient
• Surgery is a tool that requires a strong commitment from the patient and
treatment team to accommodate the lifestyle changes and the lifetime of
follow-up
– Bariatric surgery should be synergistic with other therapies
– Follow-up care should include managing medications, complications, and patient
expectations
– Identify and access support groups
– Ongoing communication
Talk to your patients!



Discuss available treatment options
If appropriate, refer them to a bariatric surgeon
Provide information on local patient seminars
29
Bariatric Surgery Clinical Study Results
Results
Investigator
Study type
# of
patients
Study start year
Duration
Study
publication
RCT, single center
80 pts
2002
3 years
Obse Surg
43
studies
Incl. studies published
prior to 2005
10 years
Obse Surg
O’Brian
et al.
Systematic review, studies of
≥100 pts and ≥3 yrs. weight
loss data
Systematic review, studies of
≥100 pts and ≥3 yrs. weight
loss data
43
studies
Incl. studies published
prior to 2005
10 years
Obse Surg
O’Brian
et al.
Excess weight loss:
66% Excess weight loss at 3 years,
Sleeve Gastrectomy28
62% Excess weight loss at 3 years,
Gastric Bypass35
55% Excess weight loss at 3 years,
Gastric Band35
Himpens
et al.
Obesity-related conditions:
T2DM: 68% of patients resolved14
STAMPEDE
Schauer et al.
RCT single center
150 pts
2007
3 years
N Engl J Med
High blood pressure: 66% of
patients resolved45
Tice
et al.
Systematic review of 14
studies
NA
Incl. studies published
prior to 2007
1 year
Am J Med
High cholesterol: 94% of patients
improved46
Buchwald
et al.
Systematic review and metaanalysis of 91 studies
22094 pts
2004
NA
JAMA
Osteoarthritis/degenerative joint
disease: 41% of patients resolved47
Schauer
et al.
Prospective, single center
275 pts
1997
3 years
Ann Surg
Obstructive sleep apnea: 76% of
patients resolved 45
Tice
et al.
Systematic review of 14
studies
NA
Incl. studies published
prior to 2007
1 year
Am J Med
Cancer: 38% reduction in incidence
of obesity related cancer48
Adams
et al.
Retrospective, multi center
16038
1984
24 years
Obesity
28. Himpens, J. (2006). A Prospective Randomized Study Between Laparoscopic Gastric Banding and Laparoscopic Isolated Sleeve
Gastrectomy: Results after 1 and 3 Years. Obes Surg, 16 (11): 1450-1456. 35. O'Brien PE, McPhail T, Chaston TB, et al. Systematic review of
medium-term weight loss after bariatric operations. Obes Surg. 2006; 16(8):1032-1040. 14. Schauer P, et al. Bariatric Surgery versus Intensive
Medical Therapy in Obese Patients with Diabetes. N Engl J Med 2012; 366:1567-1576; April 26, 2012." 45. Tice JA, Karliner L, Walsh J, et al.
Gastric banding or bypass? A systematic review comparing the two most popular bariatric procedures. Am J Med. 2008 Oct;121(10):885-93 46.
Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004 Oct 13;292(14):1724-37 47.
Schauer PR, Ikramuddin S, Gourash W, et al. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg. 2000
30
Oct;232(4):515-29. 48. Adams T, Stroup A, Hunt S et al. Cancer Incidence and Mortality After Gastric Bypass Surgery. Obesity. 2009;17(4):796802.
Appendix
© 2015 Ethicon US, LLC. All rights reserved. 040042-150909
31
Obesity and cancer
Weight loss after bariatric surgery
Patient considerations
•
The risk of developing and dying from many common
cancers is increased in individuals with obesity.1
•
By 2030, nearly 500,000 Americans are projected to be
diagnosed with obesity-associated cancers annually2
–
–
•
In men: may account for 14% of all
In women: may account for 20% of all deaths3
Excess weight loss of +25% at 5years.6
•
The reduced weight after bariatric surgery may
contribute:
Men: esophageal cancer (by 52%) and colon cancer (by 24%) 4
Women: endometrial cancer (by 59%), gallbladder cancer (by
59%), and postmenopausal breast cancer (by 12%) 4
Cancers affected by obesity include:1,4 Endometrial cancer,
cervical cancer, ovarian cancer, Postmenopausal breast cancer,
colorectal cancer, esophageal cancer, pancreatic cancer,
gallbladder cancer, liver cancer, kidney cancer, thyroid cancer,
prostate cancer, non-hodgkin’s lymphoma, multiple myeloma and
leukemia.
Mechanism of action
•
•
Each 5-kg/m2 increase in BMI may increase the risk for:
‒
‒
‒
deaths3
Research has shown that with weight loss following a
sleeve gastrectomy or gastric bypass surgery, the
following types of results are seen and may be possible -
The function of adipose tissue as an endocrine organ
may contribute to cancer risk:5
‒
Estrogen and adipokines affect biochemical signals and have
been linked to some forms of cancer2
‒
There are increased levels of factors known to be linked to
tumor development2
•
–
a significantly reduced incidence (57% lower risk) of
obesity-related cancer in individuals post bariatric
surgery compared with no bariatric surgery7
–
80% less likely to develop any cancer compared with
their equally overweight counterparts who did not have
surgery8
Note: The impact on cancer of weight loss following bariatric surgery
may be associated only with cancers that are related to a patient's obesity.
According to the American Society of Clinical Oncology, obesity
contributes to up to 20% of cancer incidence, linked to poorer cancer
outcomes and a risk for the development of comorbid illness in
cancer survivors.9
Bariatric surgery is used in morbidly obese adult patients for significant long-term weight loss.
Results following bariatric surgery may vary. Bariatric surgery may be appropriate for some
patients, and not for others depending on their specific weight, age, and medical history.
Patients and doctors should review all available information on non-surgical and surgical options
in order to make an informed treatment decision.
ETHICON manufactures and markets general surgical instruments used in bariatric surgery. The
potential benefits discussed are associated with the patient’s weight loss following bariatric
surgery, not with the use of the instruments. ETHICON is offering this information in good faith
as an educational overview to published literature in this area and a starting point for further
research. It is not intended to constitute medical advice or recommendations.
BMI=body mass index.
1. Calle EE, Rodriguez C, Walker-Thurmond K. Overweight, obesity, and mortality from cancer in a prospectively studied cohort of adults. N Engl J Med. 2003;348(17):16251638.2. Obesity and cancer risk. National Cancer Institute Web site. http://www.cancer.gov/about-cancer/causes-prevention/risk/obesity/obesity-fact-sheet. Reviewed January
3, 2012. Accessed October 27, 2015. 3. Klein S, et al. In: Melmed S, et al, eds. Williams Textbook of Endocrinology. 12th ed. Philadelphia, PA: Saunders Elsevier; 2011:16051632. 4. Renehan AG, et al. Body-mass index and incidence of cancer: a systematic review and meta-analysis of prospective observational studies. Lancet. 2008;371(9612):
569-578. 5. Kershaw EE, et al. Adipose Tissue as an Endocrine Organ. J Clin Endocrinol Metab. 2004;89(6):2548-2556. 6. Brethauer, SA. Can Diabetes Be Surgically
Cured? Long-Term Metabolic Effects of Bariatric Surgery in Obese Patients with Type 2 Diabetes Mellitus. Ann Surg 2013;258 (4): 628-636. 7. Yang XW, et al. Effects of
Bariatric Surgery on Incidence of Obesity-Related Cancers: A Meta-Analysis. Med Sci Monit. 2015;21:1350-1357. 8. Christou NV, et al. Surgery Decreases Long-term
32
Mortality, Morbidity, and Health Care Use in Morbidly Obese Patients. Surg Obes Relat Dis. 2008;4(6):691-695. 9. Obesity and Cancer: A Guide for Oncology Providers.
American Society of Clinical Oncology Website. http://www.asco.org/sites/www.asco.org/files/obesity_provider_guide_final.pdf Accessed January 28, 2016.
043514-151117
Obesity and orthopedic conditions
Patient considerations
Data has shown• An association may exist between increased BMI
and premature lower-extremity degenerative joint
diseases, chronic low back pain, and
osteoarthritis1
•
Men have a higher risk ratio than women for
obesity.1 However, women have a 4x greater
likelihood of some conditions than normal-weight
counterparts.2
Mechanism of action
•
Increased weight causes extra force through the
joints
•
Increased adipose tissue can contribute to
biological changes that can contribute to the
degradation of cartilage:3
–
High amounts of leptin are proinflammatory and catabolic
in cartilage metabolism
–
Resistin and adiponectin modulate the inflammatory
process surrounding osteoarthritis and compound
damage to the joints
–
A disordered state of glucose and lipid metabolism
induces collagen stiffness and processes that cause
cartilage degradation
Weight loss after bariatric surgery
Research has shown that post sleeve gastrectomy and
gastric bypass surgery there is weight loss that drives
health improvements•
Weight loss can reduce the odds of developing knee
osteoarthritis by 50% among women4
•
In most patients, sleeve gastrectomy and gastric
bypass surgeries produce excess weight loss of +25%
at 5years5
•
Weight loss post bariatric surgery has been shown to
result in:
–
Resolution in arthropathy : 91% of patients6
–
Decrease in the number of daily medications6
–
Reduction in chronic pain: 89% of patients7
According to the American Academy of Orthopaedic Surgeons,
obesity is a major contributor to some orthopedic conditions.8
Bariatric surgery is used in morbidly obese adult patients for significant long-term weight loss.
Results following bariatric surgery may vary. Bariatric surgery may be appropriate for some
patients, and not for others depending on their specific weight, age, and medical history.
Patients and doctors should review all available information on non-surgical and surgical
options in order to make an informed treatment decision. ETHICON manufactures and
markets general surgical instruments used in bariatric surgery. The potential benefits
discussed are associated with the patient’s weight loss following bariatric surgery, not with
the use of the instruments. ETHICON is offering this information in good faith as an
educational overview to published literature in this area and a starting point for further
research. It is not intended to constitute medical advice or recommendations.
BMI=body mass index.
1. Guh DP, et al. BMC Public Health. 2009;9:88. 2. Anderson JJ, et al. Am J Epidemiol. 1988;128(1):179-189. 3. Sowers MR, et al. Curr Opin
Rheumatol. 2010;22(5):533-537. 4. Felson DT, et al. Arthritis Rheum. 1998;41(8):1343-1355. 5. Brethauer SA, et al. Ann Surg 2013;258 (4): 628636. 6. Nelson LG, et al. Surg Obes Relat Dis. 2006;2(3):384-388. 7. McGoey BV, et al. J Bone Joint Surg Br. 1990;72(2):322-323. 8. American
Academy of Orthopaedic Surgeons. Position Statement 1184. 2015. Retrieved from http://www.aaos.org/CustomTemplates/Content.aspx?id=
22330&ssopc=1. Last accessed February 11, 2016.
043513-151117
33
Obesity and diabetes
Patient considerations
•
•
•
More than 90% of patients with type 2 diabetes (T2DM) are Research has shown that post sleeve gastrectomy and gastric
overweight1, 15% of patients that have obesity have T2DM2 bypass surgery there is weight loss that drives health
Diabetes is one of the top ten leading causes of US deaths. 3 improvementsRisk for having T2DM begins at a BMI of 22 kg/m2 and
increases by 25% for each additional BMI unit4




•
Weight loss after bariatric surgery
BMI 25 > 4% incidence of T2DM
BMI 30 > 8%
BMI 35 > 17%
BMI 40 > 22%
Age plays a role - In an adult aged 50 years with a BMI of
30 to 35 kg/m2, the incidence of diabetes increases by
750%5 compared to a normal weight individual
Mechanism of action
•
Increased adipose tissue results in higher free fatty acid
levels, reducing insulin sensitivity and impairing the
function of β-cells in the pancreas6
•
Additionally, adiponectin tends to be decreased in
patients with obesity, which may also increase insulin
resistance6
•
Resolved (78.1%) or improved (86.6%) diabetes or
obesity-related conditions,7 and reducing the risk of T2DM.
•
Post surgery there was a reduction of medication for
diabetes (down 75% after 12 months)8 and insulin usage
(only 1/3 of pre-op insulin takers still taking insulin 5 years
post op9)
•
The Ethicon funded STAMPEDE clinical trial (n=140)
showed more effective management of diabetes (
defined as HbA1c <6) in patients with medical therapy
following RYGB and SG.10
–
3 years post surgery, glycemic control was achieved in patients
undergoing RYGB (38%) and SG (24%) with medical therapy,
higher than patients who received medical therapy alone (5%)
American Diabetes Association (ADA) Statement:
“Bariatric surgery should be considered for adults with BMI ≥ 35
kg/m2 and Type 2 Diabetes, especially if the diabetes is difficult
to control with lifestyle and pharmacologic therapy.”11
BMI=body mass index; RYGB=Roux-en-Y gastric bypass; SG=sleeve gastrectomy; STAMPEDE=Surgical
Therapy and Medications Potentially Eradicate Diabetes Efficiently. 1. Obesity and overweight. World Health
Organization Web site. http://www.who.int/dietphysical activity/media/en/gsfs_obesity.pdf. 2003. Accessed
October 27, 2015. 2. Brethauer S, et al. Obesity. In: Carey WD, ed. Current Clinical Medicine. 2nd ed. Philadelphia: Saunders/ Elsevier; 2010. 3. Centers for Disease Control and Prevention. National Diabetes Statistics
Report: Estimates of Diabetes and Its Burden in the United States, 2014. Atlanta, GA: U.S. Department of Health and Human Services; 2014. 4. Clinical Guidelines on the Identification, Evaluation, and Treatment of
Overweight and Obesity in Adults: The Evidence Report. Bethesda, MD: National Heart, Lung, and Blood Institute; 1998 . NIH publication 98-4083. http://www.nhlbi.nih.gov/files/docs/guidelines/ob_gdlns.pdf. Accessed
October 27, 2015. 5. Erixon F, et al. Investing in Obesity Treatment to Deliver Significant Healthcare Savings: Estimating the Healthcare Costs of Obesity and the Benefits of Treatment. Brussels, Belgium: European
Centre for International Political Economy; 2014. ECIPE occasional paper 1/2014. http://www.ecipe.org/app/uploads /2014/12/ OCC12014_1.pdf. Accessed October 27, 2015. 6. McKenney RL, et al. Surg Clin North
Am. 2011;91(6):1139-1148. 7. Buchwald H, et al. Am J Med. 2009;122(3):248-256. 8. Segal J, et al. Obes Surg. 2009;19:1646-1656. 9. Data on File, Ethicon 2015, Optum Analysis. 10. Schauer PR, et al. N Engl J
Med. 2014;370(21): 2002-2013. 11. Handelsman Y, et al. Diabetes Care 2009; 32(S1):S13-S61.
Bariatric surgery is used in morbidly obese adult patients for significant long-term weight loss. Results following bariatric surgery may vary. Bariatric
surgery may be appropriate for some patients, and not for others depending on their specific weight, age, and medical history. Patients and doctors
should review all available information on non-surgical and surgical options in order to make an informed treatment decision. ETHICON manufactures
and markets general surgical instruments used in bariatric surgery. The potential benefits discussed are associated with the patient’s weight loss
following bariatric surgery, not with the use of the instruments. ETHICON is offering this information in good faith as an educational overview to published
34
literature in this area and a starting point for further research. It is not intended to constitute medical advice or recommendations.
043511-151117
Obesity and obstructive sleep apnea
Weight loss after bariatric surgery
Patient considerations
•
~77% of individuals with obesity experience OSA1
‒
Often underdiagnosed and undertreated1
•
The incidence of OSA is 12x to 30x greater in
patients who are severely obese2
•
In patients with a BMI above 40 kg/m2, OSA occurs
in more than 50% of cases3
Mechanism of action
•
Research has shown that post sleeve gastrectomy and gastric
bypass surgery there is weight loss that drives health
improvements•
In most patients there is excess weight loss of +25% at
5years7
•
Improvements in or resolution of sleep apnea occurred in
88.5% of patients8
•
Post bariatric surgery with associated weight loss, research
shows a decrease in respiratory disturbance index of 89%
to 98%9
•
Improvement in nocturnal oxyhemoglobin saturation,
subjective daytime somnolence, and sleep continuity and
architecture, as well as decrease in cardiac dysrhythmias9
may occur post bariatric surgery when there is weight loss
Increased throat muscle relaxation and throat
closure4:
‒
Change in anatomic factors caused by increased fat
mass5 contribute to narrow airways
‒
Reduction in lung volume associated with obesity limits
diaphragmatic descent6
‒
Increased lateral pharyngeal wall thickness and fat
deposits in the throat narrow the airway6
Bariatric surgery has been identified by medical societies such as the
American Heart Association10 and Academy of Nutrition and Dietetics
as the most successful therapy for morbid obesity.11
*
Including increased total sleep time, percentage of slow- wave sleep, and percentage of rapid eye movement sleep. BMI=body mass index; OSA=obstructive sleep apnea. 1. Kaul A,
et al. Surg Clin North Am. 2011;91(6):1295-1312, ix. 2. Piché MÈ, et al. Can J Cardiol. 2015;31(2):153-166. 3. Resta, O, et al. Int J Obes Relat Metab Disord. 2001;25(5):669-675.
4. Obstructive sleep apnea: causes. Mayo Clinic Web site. http://www.mayoclinic.org/diseases-conditions/obstructive-sleep-apnea/basics/causes/con-20027941. June 15, 2013.
Accessed October 27, 2015. 5. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. Bethesda, MD: National
Heart, Lung, and Blood Institute; 1998. NIH publication 98-4083. http://www.nhlbi.nih.gov/files/docs/guidelines/ob_gdlns.pdf. Accessed October 27, 2015. 6. Dempsey JA, et al.
Physiol Rev. 2010;90(1):47-112. 7. Brethauer SA, et al. Ann Surg 2013;258 (4): 628-636. 8. Sarkhosh K, et al. Obes Surg. 2013;23(3):414-423. 9. Koenig SM. Am J Med Sci.
2001;321(4):249-279. 10. Poirier P, Circulation. 2011;123:1683–1701. 11. Hoelscher D, et al. J. Acad. Nutr. Diet. 2013;113(10):1375-1394.
Bariatric surgery is used in morbidly obese adult patients for significant long-term weight loss. Results following bariatric surgery may
vary. Bariatric surgery may be appropriate for some patients, and not for others depending on their specific weight, age, and medical
history. Patients and doctors should review all available information on non-surgical and surgical options in order to make an informed
treatment decision. ETHICON manufactures and markets general surgical instruments used in bariatric surgery. The potential benefits
discussed are associated with the patient’s weight loss following bariatric surgery, not with the use of the instruments. ETHICON is
35
offering this information in good faith as an educational overview to published literature in this area and a starting
043516-151117
point for further research. It is not intended to constitute medical advice or recommendations.
Obesity and cardiovascular conditions
Effectiveness of weight loss after
bariatric surgery
Patient considerations
With obesity, studies show:
• an increased incidence of CV morbidities, such as
hypertension, insulin resistance, dyslipidemia, all CV
diseases, and all-cause mortality1
• Hypertension is 6x more
for patients with morbid
obesity (BMI at or above 40 kg/m2) than a normal
weight individual, a 52.3% incidence.3
likely2
• there is increased dyslipidemia, increased triglycerides,
apolipoprotein B, and LDL/HDL cholesterol levels1
Research has shown that with weight loss following a sleeve
gastrectomy or gastric bypass surgery, the following types of
results are seen and may be possible •
Excess weight loss of +25% at 5years8
•
Resolving or reduction of at least one type of CV
conditions:
–
–
•
A 33% reduction in the relative risk of first-time fatal or
nonfatal myocardial infarction or stroke6
•
Improved physical function, energy levels, perception of
general health, chest pain, and shortness of breath7
•
Decreases in medication use for hypertension and
hyperlipidemia in diabetic patients —down 45% and 55%
at 12 months, respectively 9:
Mechanism of action
•
A high BMI can lead to alterations in cardiac structure
and function4
•
Studies show an association between obesity and
increased sodium retention, increased sympathetic
nervous system activity, insulin resistance, and renin–
angiotensin system alterations4
Sleeve gastrectomy: 50%5
Gastric bypass: 66%11
The American Heart Association and Academy of Nutrition and Dietetics
identified bariatric surgery as the most successful therapy for morbid obesity.10
BMI=body mass index; CV=cardiovascular; HDL=high-density lipoprotein; LDL=
low-density lipoprotein. 1. Nader N, et al. In: Bope ET, et al, eds. Conn's Current
Therapy 2012. Philadelphia, PA: Elsevier Saunders; 2012:752-757. 2. Poirier, P et al. Bariatric Surgery and Cardiovascular Risk Factors. Circulation. 2011; 123:1684. 3. Nguyen NT, et al. Association of
Hypertension, Diabetes, Dyslipidemia, and Metabolic Syndrome with Obesity: Findings from the National Health and Nutrition Examination Survey, 1999 to 2004. J Am Coll Surg. 2008;207(6):928-934. 4.
Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report. Bethesda, MD: National Heart, Lung, and Blood Institute; 1998. NIH publication
98-4083. http://www.nhlbi.nih.gov/files/docs/guidelines/ob_gdlns.pdf. Accessed October 27, 2015. 5. Pories W, et al. Who Would Have Thought It? An Operation Proves to Be the Most Effective Therapy for
Adult-Onset Diabetes Mellitus. Ann Surg. 1995; 222(3):339-352. 6. Tham JC, et al. Cardiovascular, Renal and Overall Health Outcomes After Bariatric Surgery. Curr Cardiol Rep. 2015;17(5):34. 7. Sjöström L,
et al. Bariatric Surgery and Long-term Cardiovascular Events. JAMA. 2012;307(1):56-65. 8. Brethauer, SA. Can Diabetes Be Surgically Cured? Long-Term Metabolic Effects of Bariatric Surgery in Obese
Patients with Type 2 Diabetes Mellitus. Ann Surg. 2013;258 (4):628-636. 9. Segal JB, et al. Prompt Reduction in Use of Medications for Comorbid Conditions After Bariatric Surgery. Obes Surg. 2009; 19:16461656. 10. Poirier, P et al. Bariatric Surgery and Cardiovascular Risk Factors. Circulation. 2011; 123:1684; Deanna M, et al. Position of the Academy of Nutrition and Dietetics: Interventions for the Prevention
and Treatment of Pediatric Overweight and Obesity. J. Acad. Nutr. Diet. 2013;113 (10): 1375-1394. 11. [EES weighted analysis of data summarized in table 4 of] Brethauer SA,et al. Systematic review of sleeve
gastrectomy as staging and primary bariatric procedure. Surg Obes Rel Dis. 2009;5(4):469-475.
Bariatric surgery is used in morbidly obese adult patients for significant long-term weight loss. Results following bariatric surgery may vary.
Bariatric surgery may be appropriate for some patients, and not for others depending on their specific weight, age, and medical history.
Patients and doctors should review all available information on non-surgical and surgical options in order to make an informed treatment
decision. ETHICON manufactures and markets general surgical instruments used in bariatric surgery. The potential benefits discussed are
associated with the patient’s weight loss following bariatric surgery, not with the use of the instruments. ETHICON is offering this information
36
in good faith as an educational overview to published literature in this area and a starting point for further research.
043515-151117
It is not intended to constitute medical advice or recommendations.
Questions?
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37