1. RBH Obesity Pathway Theingi Aung & Greg Jones RBH 23 rd September 2015

2. Prevalence of Obesity Increasing at a epidemic rate globally 2.3 billions adults-overweight 700 millions-clinically obese Expected to rise further WHO; Obesity and overweight: fact sheet 311

3. Country*Adult Obesity (%) Adult Overweight (%) Combined Obese and Overweight (%) Brazil17.433.651.0 Bulgaria23.734.558.2 Canada18.434.152.5 Denmark14.133.347.4 England24.837.161.9 France15.032.647.6 Germany23.636.560.1 Italy10.336.546.8 Mexico32.239.171.3 Spain22.939.462.3 United States35.733.168.8 Adapted from European Association for the Study of Obesity

4. Prevalence of obesity among adults aged 16+ years Health Survey for England 1993-2012 (3-year average)

5. Prevalence of Obesity West Berkshire –BMI >50 N= 922 –BMI 40-50 N= 3559 –BMI 30-40N= 2685

6. Diabetes Gall bladder disease Hypertension Dyslipidaemia Sleep apnoea Breathlessness Nonalcoholic fatty liver disease Greatly increased (relative risk >>5) Coronary heart disease Osteoarthritis (knees) Hyperuricaemia and gout Cancer (postmenopausal breast cancer, endometrial cancer, colon cancer, prostate cancer, oesophageal cancer) Polycystic ovary syndrome Impaired fertility Obstetric complications Increased anaesthetic risk Moderately increased (relative risk 2-3) Increased (relative risk 1-2) Relative risk of health problems associated with obesity Low back pain Gastro-oesophageal reflux disease

7. NBSR Report 2014-DM outcome

11. Models of care Tier 4 - Specialised Complex Obesity Services (including bariatric surgery) Tier 3 - MDT obesity service to provide an intensive level of input to patients. Tier 2 - Primary Care with Community Interventions Tier 1 - Primary Care and Community Advice

12. Tier 3/4 Specialist Complex Obesity Service at RBH 1.Eligibility criteria 2.Referral 3.MDT assessment and optimisation of medical conditions before surgery 4.Pre-op preparation programme & review 5.Surgical MDT 6.Pre-op clinic 7.Surgery 8.Post surgical care pathway

13. Clinical Commissioning Policy: Complex and Specialised Obesity Surgery (Tier 4) BMI > 40kg/m 2 BMI >35 kg/m 2 in the presence of other significant diseases Age <65 yr There must be formalised MDT led processes for – the screening of co-morbidities – the detection of other significant diseases – The medical evaluation is mandatory prior to entering a surgical pathway. Morbid/severe obesity has been present for at least five years.

14. Bariatric surgery for recent onset type 2 diabetes Consider Bariatric surgery with: – expedited assessment for BMI 35+ and recent onset T2DM. – with a BMI of 30-34.9 with recent onset T2DM – Lower BMI in Asian population with recent onset T2DM as long as they are receiving or will receive assessment in tier 3 service.

15. Mode of referral Choose & Book (medical team not surgical) Letter direct to bariatric team Referrals from other specialities

17. Time line of assessment of RBH Obesity pathway for surgery Baseline Medical MDT (Endocrinologist, Specialist dietician, clinical psychologist) BSN-group sessions 6-months 3 months life style groups secssions (Specialist dietician, clinical psychologist) Medical investigations & treatment of Co-morbidities; 1:1 section for intensive input-selective patient 10-12 months Review by medical MDT clinic (notes) review medical review, weight target, patient engagement to programme, Low calorie diet pathway 12-18 months Surgical MDT: Medical team, Surgeons & Anaesthetics Follow-up Drop in clinics, Band adjustments, Group supports, Medical reviews RBH Care pathway is available only for patients who want bariatric procedure; no medical pathway is currently not available: Exception: for BMI>50: minimum period of assessment 6 months.

18. Surgical MDT Discuss difficult cases and see pre-op patients Includes: – Consultant Bariatric Surgeon (3) – Metabolic Physician/Endocrinologist (1) – Consultant Bariatric Anaesthetist (2) – Specialist Dietician (2) – Bariatric Nurse Specialist (1) – Clinical Psychologist with Bariatric interest (2) – Specialist Nurse in Endocrine and Bariatric (1) – Surgical Pharmacist with Bariatric Interest (1) – Consultant Radiologist with Gastrointestinal and Bariatric interest (1)

19. Pre-op Discussion (Nice CG 189) Potential benefits Longer-term implications for surgery Associated risks Complications Peri-operative mortality Consent process in clinic All patients re-discussed at end of clinic and confirmation of surgery agreed

20. Surgical procedures at RBH Laparoscopic Adjustable Gastric band Laparoscopic Sleeve gastrectomy Laparoscopic Roux-en-y gastric bypass Gastric balloon Revisional Bariatric surgery

21. Lap-Band

22. Gastric Bypass

23. Sleeve Gastrectomy  Ghrelin  GLP-1  PYY

24. Post-op care In hospital: – Day of operation – water – Day 1 – free fluids – Day 2 – discharged home – Daily consultant review – Due to start an Enhanced recovery programme On discharge: – All – Multivitamins, LMW heparin (2 week) – Sleeve/bypass Ferrous fumerate Calcit D3 Vitamin B12 Lansoprazole fast tab (3 months)

25. Follow-up (Nice CG 189) Minimum 2 years within the bariatric service, including: – Monitoring nutritional intake and deficiencies – Monitoring co-morbidities – Medication review – Dietary and nutritional assessment – Physical activity advice and support – Psychological support tailored to the individual – Peer support After discharge from bariatric service: – Annual monitoring of nutritional status and appropriate supplementation – Shared care model of chronic disease

26. Gastric band follow up Surgical Clinic – 4 weeks – 4 months Radiology- first band fill – 6-8 weeks Specialist Nurse for band adjustment – 12 weeks – monthly until correct fill – 3 months – 6months Specialist Nurse short notice/rescue clinic

27. Bypass/sleeve follow up Surgical clinic: – 4 weeks – 4 months – 12 months – Rescue appointments if needed Dietician: – 3 monthly in first year – 6 monthly until 2 years Drop in sessions for post-op: monthly at Diabetes centre)

28. Blood tests To be performed at patients General Practice Results to be acted upon by bariatric unit Band – FBC, U& E, LFT annually Bypass/Sleeve – FBC, U&E, LFT, Ferritin, Folate, Calcium, Vitamin D, PTH, 3, 6, 12 months in first year and then annually – Vitamin B12 6, 12 months and then annually – Zinc, copper Annually

29. Micronutrient replacement All patients to buy – Complete A-Z multi-vitamin and mineral GP to prescribe for sleeve and bypass patients – Calcium and Vit D Combined (Calcit D3) daily for life – Vitamin B12 injection 3 monthly – Iron Supplement (Ferrous Fumarate) Daily for life

30. Time line of assessment of RBH Obesity pathway for surgery Baseline Medical MDT (Endocrinologist, Specialist nurse, Specialist dietician, clinicla psycologist) 6-months 3 months life style groups secssions (Specialist dietician, clinical psychologist) Medical investigations & treatment of Co-morbidities; 1:1 section for intensive input 10-12 months Review by Endocrinologist/MDT notes clinic medical review, weight target, patient engagement to programme 12-18 months Surgical MDT: Medical team, Surgeons & Anaesthetics Follow-up Drop in clinics, Band adjustments, Group supports, Medical reviews RBH Care pathway is available only for patients who want bariatric procedure; no medical pathway is currently not available: Exception: for BMI>50: minimum period of assessment 6 months.