Slide set for Workshop 2
Complex Obesity Cases
Acknowledgments C Hughes
WORKBOOK PAGES 12- 20
Workshop 2
Complex Obesity
Cases
Aims
Review incidence of complex obesity
Look at recommended clinical pathways
Review the options available for
treatment
Case discussions
Severe obesity BMI >40 kg/m2 is the fastest
growing category of obesity
A recent systematic review (Tsai et al) noted the
disproportionate economic burden associated with severe
and complicated obesity. 15% of obese population have
severe obesity but account for 35% of the total obesity
costs.
NICE CG 189 recommends
• Offer referral to a Tier 3 unit for treatment
• Consider bariatric surgery if BMI >40 kg/m2 or > 35kg/m2
with co-morbidities.
• Bariatric surgery treatment of choice if BMI>50 kg/m2
Obesity services 2013 Dept of Health
Tier 3 services - part of a pathway
Public health interventions and Tier 2 services are costeffective for many people
Tier 3 services must integrate fully into the obesity
pathway
Aim is to improve health by losing weight and making
permanent modifications to habits and behaviour to
support weight maintenance and a healthy lifestyle
Multi-disciplinary team for complex patients
Bariatric surgery is an appropriate outcome for some
patients
Description of Tier 3service
• Multicomponent medical service offering dietary and
activity advice, pharmacotherapy, psychological therapy,
VLCD, and assessment and preparation for bariatric
surgery in line with NICE guidance (CG 189 2014)
• Specialist equipment and on-site gym
• Individual monthly appointments plus group interventions
• High degree of patient participation
• Monthly patient led support group post discharge
• Facebook support group (patient run)
• Research Active
Italics - specific for Fakenham Weight Management Service
Multi-disciplinary Team
Dedicated administrator
General Practitioner with specialist training (SCOPE certification) or
Endocrinologist/bariatric Physician
Obesity specialist nurses (OSNs)
Dietician
Psychologist or Psychologically trainer practitioner
Health trainer
Exercise professional/physiotherapist
Occupational therapist
Also clinical core group including endocrinologist, clinical
psychologist, Public health, patient representatives x3, and CCG
representative
Italics - specific for Fakenham Weight Management Service
Case One
Mrs A is 46 year old carer and has struggled with her weight for
many years. She now has degenerative changes to her L knee
which is affecting her home and working life.
Orthopaedic team will not operate until BMI 30kg/m2.
She was only concerned about her knee pain and her job, and
was not very interested in bariatric surgery.
Examination; no signs of endocrine abnormality. It was noted
that both arms were significantly scarred.
PMH; Asthma, depression and self-harm, impaired fasting
glycaemia.
Medication; Naproxen 500mg bd, Co-dydramol 8 a day
Discussion points
What would you want to know about Mrs A with regard to her ‘weight
history’?
Would you want to know more about her mental health? And why?
What first-line bloods would you arrange?
What would you consider to help her lose weight?
What do you think about the orthopaedic surgeons setting a BMI
target?
Case 1 actual result
She was put on LELD and lost around 20kg,
her knee pain resolved and she was able to
stop all painkillers. She was discharged to her
GP at 129kg, on orlistat for further support to
continue to lose weight, or maintain weight
loss.
2 years after discharge her weight was 145kg
Discussion point: should she have been referred
for bariatric surgery after her initial weight loss?
Case 2
Mr C, 41 year old man
Seen at a regional bariatric surgery centre in the
previous year but he then declined surgery at the last
minute.
Initial weight: 159.6 kg, BMI 50.4 kg/m2.
He lives with his disabled wife and young family. He
was previously a farm worker, now unemployed. Sits
at home playing games on computer all day.
Examination; no signs of endocrine disease, normal
heart sounds
PMH; Severe obstructive sleep apnoea, OA
feet/hands.
Medication; Nil
Discussion points
At his first appointment how would you explore Mr C’s expectations
for weight loss and his motivation?
How could you motivate Mr C to become more active?
Mr C has severe sleep apnoea. What is its relevance?
What blood tests would you want to arrange prior to referring a
patient for bariatric surgery?
What other information might the surgical centre require?
Case 2 actual result
He lost about 3 kg with intensive support from specialist
nurses and dietitian
He did not tolerate LELD
Hard to get him more physically active
Psychological therapist and team persuaded him that
surgery would help him
Laparoscopic gastric bypass 2014
Excellent weight loss and no complications
Current weight 83.8kg BMI 26.5 kg/m2
Mood improved and fit to work
Case 3
Mr D, 55 year old ex-smoker, T2D since 2006 and OSA
Car breakdown repair man. Normal weight most of his life and was sporty,
weight increased over the last 10-15 years,12kg weight gain in last year
Initial weight 139kg BMI 42.9 kg/m2.
Does not attend appointments for T2D or OSA. No hypo’s but he often
omits his morning insulin. Changes his insulin dose on his own rules
Often misses breakfast, then has brunch fry up, followed by ‘garage food’
but eats better at home
Interested in bariatric surgery as he ‘wants his life back’
HBA1c 79mmol/l No diabetic nephropathy, normal FBC and renal
function, cholesterol 6.7
Examination; chronic left leg ulcer, decreased vibration sense ankles,
abdominal striae.
PMH; OSA - was on CPAP but he has discontinued, Severe OA both
knees and ankles
Spinal surgery - L4/5 laminectomy 2006 followed by DVT
Medication; 200IU lantus insulin bd, Liraglutide 1.2mg daily, Gliclazide
80mg x4 daily
Discussion points
What are the medical issues that need addressing, and how do
you start?
What dietary advice would be appropriate?
Is he a suitable candidate for bariatric surgery?
How would you counsel him about bariatric surgery?
Case 3 – initial outcome
Attended for one year
Discussion of health risks and benefits of losing weight
Individual sessions with psychological therapist
Dietary advice from dietitian and OSN
Individual appointment with medical exercise specialist
Bariatric physician appointments x4
Advised to attended respiratory and diabetic
appointments regularly
He decided against bariatric surgery
Case 3 - final result
Weight loss 28.3 kg (19.9%)
Final BMI 33.2 kg
Leg ulcer healed
Insulin reduced to 35 U daily
Walking 2 miles a day
Wife says no snoring
Attending long-term support group
Agrees to attend diabetic review appointments