The Treatment of
Obesity
Proven approaches to treating obesity
and its associated co-morbidities
DSL#12-1303
This promotional education activity is brought to you by Ethicon and is
not certified for continuing medical education. XXX is a paid consultant of
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Presentation Topics
• What is obesity?
• Obesity treatment options
• Recent clinical evidence
• Obesity patient management
What is obesity?
Obesity is a complex, multi-factorial, chronic
metabolic disease
Obesity involves the following factors:
Genetic
Metabolic
Environmental
Physiological
Behavioral
Psychological
American Obesity Association. Fact Sheet: Obesity in the U.S. May 2, 2005. http://www.obesity.org
A contributing factor to obesity is the body’s
metabolic “set point”
Sumithran P, Prendergast, LA, Delbridge E, et al. Long-term persistence of hormonal adaptations to weight loss.
N Engl J Med. 2011; 365:1597-1604.
Hormones play a significant role in controlling
weight
Dieting Triggers Hormonal &
Neuro Signals
Appetite (Ghrelin)
Satiety (PYY, CCK)
Metabolism (Leptin, Melanocortin)
Cummings DE, Weigle DS, Frayo RS et al. Plasma ghrelin levels after diet-induced weight loss or gastric bypass surgery.
N Engl J Med. 2002; 346(21): 1623-30.
Cummings DE, Schwartz M. Genetics and pathyphysiology of human obesity. Annu Rev Med 2003; 54:453-71.
The National Institute of Health uses BMI to define
obesity
• Body mass index (BMI) is:
– a measure of body fat based on height and weight.
• Morbid obesity is:
– a multi-factorial disease of excess fat storage (40+ BMI) and associated
diseases of other systems
– lifelong and progressive.
NIH Body Mass Index classifications
Between 25 and 29.9 BMI
Overweight
30 or higher BMI
Obese
40 or higher BMI
Morbidly obese
Vorvick LJ. Body Mass Index. MedlinePlus. Accessed October 9, 2012 from http://www.nlm.nih.gov/medlineplus/ency/article/007196.htm
According to NIH guidelines, here is what obesity
looks like*
Normal Weight
(BMI 19 to 24.9)
Overweight
(BMI 25 to 29.9)
Obese (Class I)
(BMI 30 to 34.9)
Obese (Class II)
(BMI 35 to 39.9 )
Morbidly Obese
(BMI 40 or more)
130 pounds
BMI 22
152 pounds
BMI 26
175 pounds
BMI 30
205 pounds
BMI 35
234 pounds
BMI 40
*For a 5’4” female
Vorvick LJ. Body Mass Index. MedlinePlus. Accessed October 9, 2012 from http://www.nlm.nih.gov/medlineplus/ency/article/007196.htm
and National Heart Lung Blood Institute. Classification of Overweight and Obesity by BMI, Waist Circumference, and Associated Disease
Risks. Accessed October 9, 2012 from http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/bmi_dis.htm
One third of the U.S. adult population is considered
obese and the number is growing
% of the population that is obese by state
1990
No Data
< 10%
2010
10%-14%
15%-19%
20%-24%
25%-29%
≥ 30%
75 million adult Americans are considered obese
Ogden CL, Carroll MD, Kit BK et al. Prevalence of obesity in the United States, 2009-2010. NCHS Data Brief 2012; 82 and Centers
for Disease Control and Prevention. US Obesity Trends, trends by state 1985-2010
There is a significant economic impact of obesity
• $168 billion is the estimated US annual medical cost of obesity1
• There is 50% higher per capita medical spending on obese patients
than for normal weight individuals1
• There is an 80% higher prescription drug spending for the obese
patient than for normal weight individuals2
• 16.5% of national health expenditures are spent treating obesityrelated illness1
Obesity is an expensive disease.
1. Cawley, J, Meyerhoefer, C. The Medical Care Costs of Obesity: An Instrumental Variables Approach. National Bureau of Economic
Research. October 2010. 2. Finkelstein EA, Trogdon JG, Cohen JW et al. Annual medical spending attributable to obesity: Payerand service-specific estimates. Health Affairs 2009; 28(5):w822-w831.
There are significant co-morbidities associated with
obesity
Pulmonary disease
abnormal PFTs
obstructive sleep apnea
hypoventilation syndrome
Nonalcoholic fatty liver
disease
steatosis
steatohepatitis
cirrhosis
Gallbladder disease
Gynecologic abnormalities
abnormal menses
infertility
polycystic ovarian syndrome
stress incontinence
Osteoarthritis
Skin
Gout
Depression
Stroke
GERD
Cardio/Metabolic
Syndrome
diabetes
dyslipidemia
hypertension
metabolic syndrome
Severe pancreatitis
Cancer
breast, uterus, cervix, colon,
esophagus, pancreas
kidney, prostate
Phlebitis
venous stasis
Premature Death
References at end of presentation
As a patient’s BMI rises, so does the prevalence of
co-morbid conditions
Prevalence of Significant Morbidities per Weight
60%
49%
50%
45%
40%
29%
30%
22%
10%
19%
17%
20%
8%
4%
4%
5%
6%
6%
0%
Diabetes
Chronic Heart Disease
BMI 25
BMI 30
BMI 40
Hypertension
BMI 40+
Stommel M, Schoenborn CA. Variations in BMI and prevalence of health risks in diverse racial and ethnic
populations. Obesity 2010; 18(9):1821-1826.
Obesity has serious consequences
• Life expectancy decreases as BMI increases
– For people with obesity, there is a 33% to 179% higher risk of mortality
14
Age
20
YEARS OF LIFE LOST
12
30
40
50
10
8
6
4
2
BMI
0
25
27
29
31
33
35
37
39
41
43
≥45
Graph represents years of life lost for white men.
Allison DB, Fontaine KR, Manson JE et al. Annual deaths attributable to obesity in the United States. 1999; 282(16):1530-1538.
Fontaine KR, Redden DT, Wang C et al. Years of life lost due to obesity. JAMA 2003;289:187.
Obesity Treatment Options
The recommended treatment for obesity depends
on the severity of the disease
National Institutes of Health. The practical guide: Identification, evaluation, and treatment of overweight and
obesity in adults. NIH Publication Number 00-4084; 2000.
Lifestyle Modifications
• Caloric intake should be reduced
by 500 to 1,000 calories per day
(kcal/day) from the current level.
• Daily food logs for 4-6 weeks
• Weekly weigh-in
• Increased physical activity
• Water intake
• Behavior modification
Lifestyle Modifications
• Comparison of weight loss/behavior programs: Atkins®, Zone, Weight
Watchers®, and Ornish Diets
Type of Diet
Completing One Year
Weight Loss at One Year
Atkins®
21/40 (53%)
2.1 kg (4 lbs.)
Zone
26/40 (65%)
3.2 kg (7 lbs.)
Weight Watchers®
26/40 (65%)
3.0 kg (6 lbs.)
Ornish
20/40 (50%)
3.3 kg (7 lbs.)
According to the Swedish Obesity Study 20 year data published in
JAMA, patients lost 1% with diet and lifestyle changes.
Dansinger ML, Gleason JI, Griffith JL, et al. Comparison of the Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart
disease reduction. JAMA 2005;293(1)43-53. Sjostrom L, Peltonen M, Jacobson P et al. Bariatric surgery and long-term cardiovascular events.
NEJM 2012; 307(1):56-65.
Atkins is a registered trademark of Atkins Nutritionals, Inc.
Weight Watchers is a registered trademark of Weight Watchers International, Inc.
Pharmacotherapy: Medications for Weight Loss
• For patients with:
– BMI ≥ 27 with co-morbidities or
– BMI ≥ 30 without co-morbidities
• There are 5 drugs currently available for patients.
– Alli®
– Xenical®
– Adipex®
– Qsymia™
– Belviq®
Trademarks are the property of their respective owners.
Pharmacotherapy
Mechanism
of action
Xenical
(orlistat)1
Alli
(orlistat)2
Blocks fat
absorption
Blocks fat
absorption
Adipex
(phentermine)3
Qsymia
(phentermine/topirama
te extended release)
Belviq
(lorcaserin
hydrocholride)
Induces satiety
Reduced appetite &
possible satiety
enhancement
Reduced
appetite & feel
fuller sooner
10 mg BID
Dosage
120 mg TID
60 mg TID
15 – 37.5 mg
QD
3.75 mg/23 mg QD for
14 days, then increase
to 7.5 mg/46 mg QD.
Dose may be titrated
higher if WL not
achieved after 12 weeks
Average
weight
Loss
5.7 lbs at 1
year
5 – 10 lbs at
6 months
7.92 lbs at 1
year
5.1%-10.9% of body
weight at 1 year
5.8% of body
weight at 1 year
Concerns
GI symptoms,
risk of liver
damage
GI symptoms
risk of liver
damage
Monitor blood
pressure
Monitor heart rate
Possible risk of
cardiac event
1.
Xenical Prescribing Information. 2. Alli product label. 3. ePocrates–Adipex-P monograph; Li Z, MaglioneM, TuW et al. Metaanalysis: Pharmacologic Treatment of Obesity. Ann Intern Med. 2005;142:532-546.
2. 4. Qsymia Pirescribing Information 5. Belviq Prescribing Information.
Bariatric & Metabolic Surgery:
• For patients with:
– BMI ≥ 35 with co-morbidities or
– BMI ≥ 40 without co-morbidities
• Provides medically significant sustained weight loss
• Involves alteration of the GI tract that affects cellular and molecular
signaling and leads to a physiologic improvement in energy balance,
nutrient utilization, and metabolic disorders.
• Examined in many clinical studies for effects on weight and comorbidities
Comparison of surgical treatment options
Treatment
Excess
Weight Loss
Laparoscopic Adjustable Gastric Banding1
41%
Sleeve Gastrectomy2
66%
Gastric Bypass Surgery3
62%
Surgery is Currently the Most Effective Treatment for Morbid Obesity
Average Weight Loss from baseline; meta-analysis of various studies up to 4 years in length.
1. Phillips E, Ponce J, Cunneen SA, et al. Safety and effectiveness of REALIZE® adjustable gastric band: 3-year prospective study in the
United States. Surg Obes Rel Dis. 2009; 5:588-597. P<0.001
2. Fischer L, Hildebrandt C, Bruckner T, Kenngott H, Linke GR, Gehrig T, Büchler MW, Müller-Stich BP. Excessive weight loss after
sleeve gastrectomy: a systematic review. Obes Surg. 2012 May;22(5):721-31.
3. 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.
Major medical societies are advocating for bariatric
surgery
“It is clear that obesity surgery today offers the only effective long-term
treatment option for the severely obese patient.”
- American Heart Association (AHA), 2011
“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.”
- ADA “The Standards of Medical Care in Diabetes,” 2009
“Weight-loss surgery is the most effective treatment for morbid obesity
producing durable weight loss, improvement or remission of co-morbid
conditions, and longer life.”
- Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), 2009
1 Poirer.P, Cornier M-A, Mazzone T. Bariatric surgery and cardiovascular risk factors: A scientific statement from the American Heart
Association.Circulation 2011;123:1683-1701.l
2 American Diabetes Association. Standards of medical care in diabetes – 2009. Diabetes Care 2009; 32 (S1): S13-S61
3 SAGES Guidelines Committee. SAGES guideline for clinical application of laparoscopic bariatric surgery.
Surg Endosc 2008 Oct;22(10):2281-300
Treatments Prescribed for Morbid Obesity
Avidor Y, Still CD, Brunner M, et al. Primary care and subspecialty management of morbid obesity: referral patterns for
bariatric surgery. Surg Obes Relat Dis. 2007;3(3):392-407
Continuum of care for the obese patient
There are many healthcare professionals that must work
together to identify the right time for the right treatment.
.* From Janssen
Surgical Options for
Obesity Treatment
Bariatric Surgery Procedure Types
A laparoscopic
approach for bariatric
surgery is performed
~90% of the time.
Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2008. Obes Surg 2009; 19:1605-1611.
Bariatric surgery – most common procedures
Roux-en-Y
Gastric Bypass
Sleeve
Gastrectomy
Adjustable
Gastric Banding
Bypass a portion of the
small intestine and create a
15-30cc stomach pouch
Re-sect approximately
three-fourths of
the stomach
Place implantable
device around upper
most part of stomach
~245,000 procedures annually (US)
Comparing the benefits and
risks of bariatric surgery
There are significant co-morbidity improvements
associated with bariatric surgery
Depression*
47% reduced
Obstructive sleep apnea
45% to 76% resolved
Asthma
39% improved
Migraines*
46% improved
Diabetes
25% to 66% controlled
Hypertension
42% to 66% resolved
Urinary stress incontinence*
50% resolved
Osteoarthritis* /Degenerative
joint disease
41% resolved
Nonalcoholic fatty liver
disease
37% resolution of steatosis
References at end of presentation. * Study population predominantly female.
90-Day Adverse Event Rates by Procedure*
*When performed at a Bariatric Surgery Center of Excellence
Serious events include death, anastomotic leakage, cardiac arrest, deep vein thrombosis,
evisceration, heart failure, liver failure, multi-system organ failure, myocardial infarction,
pneumothorax, pulmonary embolism, renal failure, respiratory failure, sepsis, stroke, systemic
inflammatory response syndrome, and bleeding requiring blood transfusion. Does not include nonserious events such as nausea/vomiting, dehydration, and atelectasis.
SRC BOLD Report: Summary of Key Statistics Prepared for SRC’s Strategic Alliance Partners. March 2010. Data is reported on 80,157
research-consented patients who have had a surgery entered in BOLD from June 2007 through Sept 22, 2009. All patients with data in BOLD
have had their bariatric surgery performed by a surgeon participating in SRC’s Bariatric Surgery Center of Excellence (BSCOE) program.
CMS: Inpatient Discharge Data (2010)
Morbidity & mortality rates of gastric bypass are similar to other common
procedures
Source: Direct Research, LLC, Center for Medicare and Medicaid Services, FY 2010 MedPAR, Medicare Fee-forService Inpatient Discharges with Selected Procedures
Bariatric Surgery: Benefits vs. Risks
• Benefits:
– Highest level of excess weight loss
– Co-morbidity resolution or reduction
– Reduction in mortality
• Risks:
– General risks of surgery
– Band erosion / slippage / leak / malfunction
– Esophageal spasm/reflux or esophageal/stomach inflammation
– Gastric perforation
– Outlet obstruction
Note: Lists are 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.
Recent Clinical Evidence
Bariatric Surgery and Medication Usage
STAMPEDE
Surgical treatment and
medications achieved
glycemic control in more
patients than medical
therapy alone.
Schauer PR, Kashyap SR, Wolski K, et al. Bariatric Surgery versus Intensive Medical Therapy in Obese
Patients with Diabetes. N Engl J Med. 2012; 366:1567-1576.
Study supported by a grant from Ethicon.
STAMPEDE results
Surgical treatment and
medications achieved
glycemic control of
HbA1c < 6.0% in more
patients than medical
therapy alone
Significantly more
diabetic patients
achieved glycemic
control following
bariatric surgery
Patients at Glycemic Control, 12 months
45%
42%*
40%
35%
37%
**
30%
25%
20%
15%
10%
12%
5%
0%
Medical Therapy
Medical Therapy +
Gastric Bypass
Medical Therapy +
Sleeve Gastrectomy
*p=0.002
**p=0.008
Glycemic control: HbA1c < 6.0% with or without diabetes medications, 12 mo after randomization. Figures
adapted from study data.
STAMPEDE results
Surgical treatment and
medications achieved
glycemic control of
HbA1c < 7.0% in more
patients than medical
therapy alone
Patients at Glycemic Control, 12 months
80%
*
70%
68%*
60%
50%
45%**
40%
Significantly more
diabetic patients
achieved glycemic
control following
bariatric surgery
30%
20%
10%
0%
0%
Medical Therapy
Medical Therapy +
Gastric Bypass
Medical Therapy +
Sleeve Gastrectomy
*p<0.001
**p<0.001
Glycemic control: HbA1c < 7.0% without diabetes medications, 12 mo after randomization. Figures
adapted from study data.
Mingrone
Bariatric surgery
resulted in better
glucose control
than did medical
therapy
Mingrone, G, et. al. Bariatric Surgery versus Conventional Medical Therapy for Type 2 Diabetes, N Engl J
Med 2012, March 26, [Epub ahead of print]
Mingrone – Results
Glycated Hemoglobin Levels during 2 Years of Follow-up
Mingrone, G, et. al. Bariatric Surgery versus Conventional Medical Therapy for Type 2 Diabetes, N Engl J
Med 2012, March 26, [Epub ahead of print]
Buchwald
(systematic review)
T2DM resolved or
improved in 87% of
patients following
bariatric surgery
Buchwald: Systematic Review & Meta-Analysis (2009)
T2DM resolved or improved in 87% of patients following bariatric surgery
100%
99%
87%
81%
87%
85%
Gastroplasty
Gastric
Bypass
80%
60%
40%
20%
0%
Total
Total
Gastric
Banding
Resolved
BPD/DS
Resolved or Improved
• Systematic review & meta-analysis reviewing 621 studies including 135,246 patients
• Overall, T2DM 87% resolved or improved (78% resolved) for patients after bariatric surgery
Buchwald H, Estok R, Farbach K, et al. Weight and Type 2 Diabetes after Bariatric Surgery: Systematic Review and Metaanalysis. Am J Med. 2009;122(3):248-256. Figure adapted from source data. Data included includes 621 studies with 888
treatment arms & 135,246 patients; 103 treatment arms with 3188 patients reported on resolution of diabetes. Resolution
based on clinical and laboratory manifestations of diabetes resolved (off diabetes medications with normal fasting blood
glucose [<100 mg/dL] or HbA1c [≤6%]),
Klein
(3 year matched
cohort analysis)
46% fewer T2DM
related claims for
patients with bariatric
surgery
Klein: 3-Year Matched Cohort Analysis (2011)
46% fewer T2DM-related claims for patients following bariatric surgery
• 56% fewer diabetes prescriptions were filled for bariatric surgery patients.
• There was a significantly lower supply cost in diabetes medication for surgery patients.
Source: Klein S, Ghosh A, Cremieux PY, Eapen S, McGavock TJ. Economic impact of the clinical benefits of bariatric surgery
in diabetes patients with BMI ≥35 kg/m2. Obesity. 2011;19:581-587.
Segal
(AHRQ 1 – year cohort study)
76% decline in diabetes
medication use at 12 months
post-surgery
Segal: AHRQ 1-Year Cohort Study (2010)
76% decline in diabetes medication use at 12 months post-surgery (p≤0.0001)
■ nonsurgical group
◊ surgical group
Source: Segal JB, Clark JM, Shore AD, et al. Prompt reduction in use of medications for comorbid conditions after bariatric surgery.
Effective Healthcare Research Report No. 28. Rockville, MD: Agency for Healthcare Research and Quality; 2010. (Fig 1, page 14)
Bolen
(5 year matched cohort analysis)
Lower proportion - and
likelihood - of having
T2DM at 5 years post
bariatric surgery
Bolen: 5-Year Matched Cohort Analysis (2012)
Lower proportion – and likelihood - having T2DM at 5yr following bariatric surgery
Source: Bolen, Shari and others. Clinical Outcomes after Bariatric Surgery: A Five-Year Matched Cohort Analysis in Seven US
States. Obesity Surgery (2012) 22: 749-763, Figure adapted from source data. Non-concurrent, matched cohort study following
22,693 persons who underwent bariatric surgery using logistic regression between groups for up to 5 years.
Swedish Obese Subjects (SOS)
Bariatric surgery appears
to be markedly more
efficient than usual care
in the prevention of Type
2 diabetes in obese
persons.
Carlsson LMS, Peltonen M, Ahlin S et al, Bariatric Surgery and Prevention of Type 2 Diabetes in
Swedish Obese Subjects. N Engl J Med 2012; 367:695-704.
Carlsson et al.
Significantly lower incidence of Type 2 Diabetes in Bariatric / Metabolic
Surgery group at 15 years
Carlsson LMS, Peltonen M, Ahlin S et al, Bariatric Surgery and Prevention of Type 2 Diabetes in
Swedish Obese Subjects. N Engl J Med 2012; 367:695-704.
50
Who to refer and how to
refer to bariatric surgery
Who is a Surgical Candidate?
• Meets National Institutes of Health Criteria:
BMI ≥ 40 (or ≥ 35 with obesity-related comorbidities)
• Common insurance requirements:
– 18 years or older
– Failed medically supervised weight loss
attempts
– Understands surgery and risks
– Acceptable operative risks (patient and
procedure)
– Stable psychological condition: interview,
psychotherapy, support groups as indicated
Having the Conversation with your Patients
• Open the discussion for them – delicately and
in a sensitive manner
• Tools can help open the discussion (e.g. BMI)
• Address your patient’s chief complaints first
• Empathy and respect are important
• Discuss the options for significant weight loss
• If interested, suggest that they attend a
seminar
What to provide for the surgical consultation
• Healthcare Provider documentation on weight loss attempts
• Letter from Healthcare Provider describing history of weight loss
attempts
– Insurance company requirement
• Medical records
• Pre-surgery H&P evaluation (if needed)
A Bariatric referral for consultation is similar to any
other specialist referral. They will examine the patient
to determine if surgery is the best option.
What to Look for in a Bariatric Surgeon / Surgical
Center
• A Center of Excellence, the hallmark of which is the prospective
database on patients including outcomes, safety data, and process
improvement
• A surgeon who works primarily as a bariatric surgeon and performs at
least 50 cases per year
• A surgeon/center that communicates at every stage in the patient
process with your office and is available to answer questions
• A program that features support groups for patient
participation and a strong commitment to the
psychological aspects of the program
Insurance Coverage
Requirements for approval depend on
insurance policy. Most require:
• BMI >40 or >35 with significant comorbidities
• Documented history of medical weight
loss attempts (3-6 months)
• 5 year weight history
• Psychological evaluation
• Nutrition counseling
Next Steps
1. In patient visits, determine which
patients are appropriate for a bariatric
surgery consult.
2. Identify bariatric surgeons in your area
who meet your standards for referral.
3. Recommend bariatric surgery to
selected obese patients
4. Rethink surgery as a therapeutic
intervention, not just for severely obese
patients*
* Schauer PR, Kashyap SR, Wolski K, et al. Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes. N Engl J
Med. 2012; 366:1567-1576 and Cohen RV, Pinheiro JC, Schiavon CA et al. Effects of gastric bypass surgery in patients with type 2
pa
diabetes and only mild obesity. Diabetes Care 2012; 35:1420-1428.
ge
How to treat the post
operative bariatric surgery
patient
Post-Op expectations
• Recovery takes time and patience.
• Weight loss amount and timing of weight
loss vary
• The diet will be strict
• Patients may experience discomfort
and pain as body heals
• Length of time to return to normal
activities varies
• For band patients, they should expect
ongoing band fill appointments
Post-Op Management
• Post-operative pneumonia / atelectasis
• Deep venous thrombosis / pulmonary embolism
• Incisional infections
• Nausea / vomiting / dehydration
• Anastomotic & staple line leak
• Thiamin deficiency
• Diarrhea
• Nutritional Screening / Supplements
• Medication Adjustments
Summary
A growing consensus favors bariatric surgery
“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.”
– American Diabetes Association (2009)
“When indicated, surgical intervention leads to significant
improvements in decreasing excess weight and comorbidities that can be maintained over time.”
– American Heart Association (2011)
“Bariatric surgery is an appropriate treatment for people with
type 2 diabetes and obesity not achieving recommended
treatment targets with medical therapies”
– International Diabetes Federation (2011)
“The beneficial effect of surgery on reversal of existing DM
and prevention of its development has been confirmed in a
number of studies”
– American Association of Clinical Endocrinologists (2011)
Sources: American Diabetes Association. Standards of medical care in diabetes – 2009. Diabetes Care 2009; 32(S1):S13-S61,
Poirier P, Cornier M-A, Mazzone T et al. Bariatric surgery and cardiovascular risk factors: A scientific statement from the American Heart Association. Circulation 2011; 123:00-00.
International Diabetes Federation. Bariatric surgical and procedural interventions in the treatment of obese patients with type 2 diabetes. 2011.
Handelsman Y, Mechanick JI, Blone L et al. American Association of Clinical Endocrinologists medical guidelines for clinical practice for developing a diabetes mellitus comprehensive plan. Endocr Prac 2011; 17(Suppl 2).
A growing consensus favors bariatric surgery
“The Endocrine Society recommends that
practitioners consider several factors in
recommending surgery for their obese patients
with type 2 diabetes, including patient’s BMI and
age, the number of years of diabetes and the
assessment of the (patient’s) ability to comply with
the long-term lifestyle changes that are required to
maximize success of surgery and minimize
complications.”
“… remission of diabetes, even if temporary, will
still lead to a reduction in the progression to
secondary complications of diabetes (such as
retinopathy, neuropathy and nephropathy), which
would be an important outcome of … surgery.”
– The Endocrine Society (March 2012)
Source: The Endocrine Society, Evaluating the Benefits of Treating Type 2 Diabetes with Bariatric Surgery, March 30, 2012.
Bariatric Surgery Conclusions
• Most effective treatment for morbid obesity (SAGES)
• Helps Type 2 diabetic patients achieve glycemic control more effectively than
intensive medical therapy within 1 year (STAMPEDE & Mingrone)
• Resolves or improves Type 2 diabetes and other obesity-related CV comorbidities
for up to 5 years (STAMPEDE , Buchwald, Klein and Bolen)
• Reduces medication use for Type 2 diabetes and other CV comorbidities for up to 3
years (STAMPEDE, AHRQ/Segal and Klein)
• Results in morbidity & mortality rates that are similar to well-established general
surgery procedures (DeMaria)
• Reduces the risk of cardiovascular death (myocardial infarction or stroke)
compared to customary intervention (Sjostrom)
• Is an acceptable treatment option for obese patients with T2DM by professional
medical societies including the ADA, AHA, IDF, AACE & the Endocrine Society.
Summary
• Obesity is a disease that is growing in prevalence and should be
treated as a medical condition
• Bariatric surgery is the most effective therapy available for morbid
obesity*
• Surgical weight loss impacts a number of co-morbidities associated
with obesity
• You can confidently make a bariatric surgery referral using clear and
accepted clinical guidelines and assessment tools
• The bariatric surgeon is a specialist available to you for the treatment
of obese patients
* Poirer.P, Cornier M-A, Mazzone T. Bariatric surgery and cardiovascular risk factors: A scientific statement from the
American Heart Association.Circulation 2011;123:1683-1701. and SAGES Guidelines Committee. SAGES guideline for
clinical application of laparoscopic bariatric surgery. Surg Endosc 2008 Oct;22(10):2281-300
References for “There are significant co-morbidities
associated with obesity”
1. Calle EE, Rodriguez C, Walker-Thurmond K. Overweight, obesity, and mortality from cancer in
a prospectively studied cohort of adults. NEJM 2003; 348(17):1625-38.
2. Koenig SM. Pulmonary complications of obesity. Am J Med Sci2001; 321(4):249-279.
3. Mattar SG, Velcu LM, Rabinovitz M, et al. Surgically-induced weight loss significantly
improves nonalcoholic fatty liver disease and the metabolic syndrome. Annals of Surgery
2005; 242(4):610-620
4. National Institutes of Health. Clinical guidelines on the identification, evaluation, and treatment
of overweight and obesity in adults. 1998; NIH Publication No. 98-4083.
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