1. Medical & Surgical Options for the Bariatric Patient Michelle Mountain, RD, B.Sc

2. Obesity in Canada 1 in 5 adults are obese
1 in 10 children have clinical obesity
Six million Canadians are living with obesity
A 2010 report estimated that direct costs of overweight and obesity represented $6 billion 4.1 % of Canada’s total health care budget

4. Distribution of BMI Categories by Sex, Ages 18 to 79, 2007-2009
Prevalence of Self-Reported Obesity by Age and Sex, Canada, 2007/08

5. Management and Prevention of Pediatric Obesity in Canada
Pediatric Obesity in Canada: Epidemiology, Etiology and Risks 1
Childhood Obesity in Canadian Children
3-fold increase in obesity in Canadian children
Based on measured heights and weights in representative Canadian sample
Classified by BMI ≥ 95th percentile
Shields, 2005
Management and Prevention of Pediatric Obesity in Canada

6. Managing Obesity as a Chronic Disease
Western Diet
Low Physical activity
Genetics
Psychology
Sleep Deprivation
Stress
Hormonal imbalances
Medications
Injury and disability

7. Managing Obesity as a Chronic Disease

9. Bariatric Medical Program
Comprehensive medical care led by an interdisciplinary team
Registered Social Worker
Registered Dietitian
Kinesiologist
Medical Internist
Non-surgical treatment of obesity, obesity related comorbidities and healthy lifestyle change

10. Bariatric Medical Program
Eligibility
18 years of age and older
BMI ≥35
BMI ≥ to 30, but less than 35 With at least one of the following comorbidities
Type II diabetes mellitus
Idiopathic intracranial hypertension
Poorly controlled hypertension
Ineligibility
Current drug or alcohol dependency (within 6 months of referral)
Recent major cancer (life threatening, within last 2 years) with active treatment where caloric restriction might exacerbate the condition
Untreated or inadequately treated psychiatric illness
(allow referrals at age >=17.5 years)
Patients willing to participate in groups
Patients willing to commit to the entire duration of the program

11. Bariatric Medical Program
Weight Loss Expectations
Lose 5-10% of current weight in 6 months and maintain loss for at least 1 year
Average kg loss per week

12. Bariatric Medical Program: Optifast Program
Program Orientation (Group Session)
Interdisciplinary Bariatric Team Assessments
Behavioral modification/education classes

13. Bariatric Medical Program: Optifast Program
CORE PROGRAM: 21 weekly classes
Including 12 weeks on Optifast
*(4 shakes per day, 5 if BMI more than 55)
&
6-7 weeks of supported reintroduction to food
* Optifast started in week 2
MAINTENANCE PHASE:
Follow up appointment at 6 months
(weeks 24/25),
1 year follow-up appointment and
2 year follow up.
Support Group from week # 24-52
(6 months).
Classes include a weigh-in, blood pressure monitoring, education and an exercise component

14. Bariatric Medical Program: Optifast Program
Registered Kinesiologist
and
Registered Nurse
Meet with all patients before start of Program
Kinesiologist determines patient’s suitability for Exercise component of Program
blood work done
Referral may be made to see RD or RSW
Medical Internist
(Dr. Glazer)
Physical Assessment to determine suitability for Program
Review of Blood Work
(PARmedX)

15. What is Optifast?
Optifast is a liquid low carbohydrate, low fat and high protein meal substitute
Available in chocolate or vanilla flavour (powder form)
4 shakes per day = 900 calories /day
Nutritionally complete with the exception of fibre
Add inulin fibre supplement
Clear fluids with no calories or added sugar are allowed
Optifast costs $100 per week
NOT covered by OHIP, ODSP, OW or private insurance plans

16. Optifast Group Session Topics
Dialectical Behaviour Therapy (DBT)
Self Esteem
Preparing for Transition
Exercise and Metabolism
Building your own Exercise Program
Managing Cues & Triggers
Eating Out/Special Occasion Dinning
Relapse Prevention
Reading labels/Shopping Smart
Preventing Weight Regain and Plateaus
Motivation & Goal Setting
Building your own Exercise Program
Who’s Responsible?
Support Systems
Cognitive Behavioural Therapy
Exercise, Diabetes and Hypertension
Staying on Track
Meal Planning
Understanding Nutrition
SMART Exercise
Welcome/Healthy Home
Support, Relationships and Communication
Motivation and Goal Setting
Intro to Exercise
Mood Over Matter
Stress Out/Changing Thoughts
Staying on Track –open group
Think Yourself Healthy
Who’s Responsible
Preparing for Transition
Getting Ready to Get Active
Making the Transition
Managing Cues and Triggers/Eating Styles (overlap)
Food Guide
Planning Meals (overlap)
Owning our Bodies/ Self-Care tools —have a check-in, co-led by SW and Kin, emotional, how do you feel about your transitions?
Self Esteem
Exercise
Label Reading/Shopping Smart (overlap)
Palatable Portions
Cooking Quick and Light
These are some of the weekly topics for the Low Calorie Diet (Optifast).
It is important to note that the meal replacement supplement will certainly help you lose weight, BUT it is the weekly facilitator-guided sessions that are essential to your long-term success! It is very important that you attend these sessions in order to learn the skills you will need to keep the weight off!

17. SAXENDA® What is SAXENDA® Who would benefit from SAXENDA®?
Contains liraglutide, an analog of human GLP-1
Acts as a GLP-1 receptor agonist
Who would benefit from SAXENDA®?
Adult patients with an initial body mass index (BMI) of:
30 kg/m2 or greater, or
27 kg/m2 or greater in the presence of at least one weight-related comorbidity (e.g., hypertension, type 2 diabetes, or dyslipidemia) and who have failed a previous weight management intervention.
Contraindications
Personal or family history of medullary thyroid carcinoma or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
Pregnant or breast-feeding women
indicated as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in

18. Maintenance dose of 3.0 mg/day
SAXENDA®
Weight Loss Excepted
Approximately 8% above lifestyle
How is it taken
Injected daily in the evening
Maintenance dose of mg/day
Side Effect
Transient Nausea
Cost
Approximately $400/month
0.6 mg
1.2 mg
1.8 mg
2.4 mg
3.0 mg
The drug liraglutide, taken at high doses, helps many with type 2 diabetes shed pounds, new research has found. The higher 3-milligram dose, approved as a weight loss drug and sold as Saxenda, produces more weight loss than the lower 1.8 mg. dose, approved as a diabetes treatment and sold as Victoza
Week 1
Week 2
Week 3
Week 4
Week 5

19. SAXENDA®
A 56 week study
Randomized, double-blind, placebo-controlled trial of 3731 patients with obesity or overweight with ≥ 1 weight-related comorbidity
Once daily Saxenda (n=2437)
Placebo (n =1225) + reduced calorie intake (~500 kcal/day deficit) and increased physical activity (150 minutes/week)
Patient without diabetes

20. SAXENDA® Significant weight loss with Saxenda® vs. placebo
64% of patients on Saxenda® lost ≥ 5% of their weight vs. 27% of patients on placebo (P<0.0001)
33% of patients on Saxenda® lost > 10% of their body weight vs. 10% of patients on placebo (P<0.0001)
Patients treated with Saxenda® mean waist circumference change of – 8.2 cm and -4.0 cam with placebo

21. Change from baseline in:
SAXENDA®
Change from baseline in:
Saxenda (n= 2437)
Placebo (n= 1225)
A1C (%)
-0.3
- 0.1
FPG (mmol/L)
- 0.4
- 0.0
SBP (mmHg)
- 4.3
- 1.5
DBP (mmHg)
- 2.7
- 1.8
Total cholesterol (mmol/L)
- 3.2%
- 0.9%
LDL cholesterol (mmol/L)
- 3.1%
- 0.7%
HDL cholesterol (mmol/L)
2.3 %
0.5%
Triglycerides (mmol/L)
- 13.6%
-4.8%

22. Bariatric Surgery in Canada

23. Bariatric Centres in Ontario
Bariatric Centres of Excellence (BCoEs)
Humber River Hospital
Guelph General Hospital
The Ottawa Hospital
St. Joseph’s Healthcare Hamilton
Thunder Bay Regional Healthy Sciences Centre
The Toronto Western Hospital
Hotel Dieu Hospital
Regional Assessment and Treatment Centres
Hotel Dieu Grace Hospital
Health Science North
Surgical Only Sites
St Michael’s Hospital Toronto
St Joseph’s Health Care Centre Toronto
Michael Garron Hospital

24. Who is considered a candidate for Bariatric Surgery?
Ontario Bariatric Network Criteria:
BMI 40 and over (based on BMI at time of referral)
BMI with 1-2 obesity related comorbidities such as diabetes, coronary heart disease, high blood pressure, sleep apnea, etc
Multiple failed weight loss attempts
Mentally and emotionally prepared for the surgery and understand its benefits, risks and limitations
Have support system in place
Can demonstrate a commitment to the required lifestyle changes

25. Who is considered a candidate for Bariatric Surgery?
Exclusion Criteria:
No active eating disorder in place
No drug, alcohol or substance abuse in the 6 months prior to surgery
Patient’s must be smoke free (including e-cigarettes and marijuana) for 6 months to qualify for surgery
Untreated major psychiatric disease
Women who want to become pregnant within the next 18 months

26. Patient Care Pathway Program Orientation (Group Session)
Interdisciplinary Bariatric Team Assessment
(RD, RSW, RN, Medical Internist, Physiatrist )
Pre-Operative Testing involving routine blood work and additional diagnostic testing
Surgeon Consult and Consent
Pre-Operative Assessment
Optifast for 2-3 weeks prior to surgery 
Surgery
Post op follow up:
1,3,6, 12 month
Yearly up to 5 years

27. Gastric Bypass
Restrictive and some malabsorption
Restrictive Only

28. Sleeve Gastrostomy

29. Duodenal switch (DS)
During Duodenal Switch surgery the surgeon reroutes a lengthy portion of the small intestine, creating two separate pathways and one common channel. The shorter of the two pathways, the digestive loop, takes food from the stomach to the common channel. The much longer pathway, the biliopancreatic loop, carries bile from the liver to the common channel.
The common channel is the portion of small intestine, usually centimeters long, in which the contents of the digestive path mix with the bile from the biliopancreatic loop before emptying into the largeintestine. The objective of this arrangement is to reduce the amount of time the body has to capture calories from food in the small intestine and to selectively limit the absorption of fat. As a result, following surgery, patients only absorb approximately 20% of the fat they intake.
The duodenal switch (DS) procedure is also known as biliopancreatic diversion with duodenal switch (BPD-DS) or gastric reduction duodenal switch (GRDS

30. Type 2 Diabetes Resolution Rates
Diabetes improvement starts rapidly after surgery, before significant weight loss has occurred.
Resolution of Type 2 Diabetes after Gastric Bypass 83.7%
The mechanism for postoperative metabolic improvements has not been fully elucidated and may be, in part, independent of weight loss.
This suggests that bariatric surgery may improve metabolic comorbidities even in patients who are not morbidly obese.

31. Resolution of Co-morbidities
Buchwald et al., JAMA 2004; 292:

32. Predictors contributing to diabetes resolution
As duration of diabetes increased, there was a trend towards reduced remission rates from 75% to 33% when duration was grouped in 2-year intervals.
Preoperative duration of T2DM great than 10 years conferred a significant reduction in successful diabetes remission after RYGB.
Hall, Pellen, Sedman & Jain., OBES SURG 2010; 20:

33. Predictors contributing to diabetes resolution
All patients returned to a normal level as it relates to HbA1c. .
Patient with IFG had significantly better post surgery HbA1c compared with insulin required patients
5.0 vs No major changes between IFG, diet controlled and oral agents.
Preoperative duration of T2DM did not result in significant differences in post operative HbA1c among the groups.
Schauer et al., Annals of Surgery 2003; 238:

34. Schauer et al., N Engl J Med 2012; 366: 1567-76.
End Point
(Glycated hemoglobin)
Medical Therapy (N=41)
Gastric Bypass (N=50)
Sleeve Gastrectomy (N=49)
P Value
Gastric Sleeve Gastric Bypass
Bypass vs Gastrectomy vs. Sleeve
Medical vs. Medical Gastrectomy
Therapy Therapy
≤ 6% - no. (%)
5 (12)
21 (42)
18 (37)
≤ 6% with no diabetes medications – no. (%)
13 (27)
< <
Baseline - %
8.9 +/- 1.4
9.3 +/-1.4
9.5 +/- 1.7
Month 12 - %
7.5 +/- 1.8
6.4 +/- 0.9
6.6 +/- 1.0
<
Body weight
Baseline (kg)
/- 14.5
/- 14.8
/- 16.5
Month 12
99.0 +/- 16.4
77.3 +/- 13.0
75.5 +/ 12.9
< <
Change in baseline
-5.4 +/- 8.0
/- 8.9
/- 8.5
< <
All patients in the gastric bypass group achieved the target HbA1c level without medications.
18 of the 49 patients in the sleeve group “ “
Only 5 of the 41 patients in the medical group “
No patients in the medical group went off diabetes medication
All patients in the gastric bypass group went off the diabetes medication
13 of the 49 in the sleeve went off diabetes medication.
Also, weight loss was much better in the surgical group.
Schauer et al., N Engl J Med 2012; 366:

35. Hormonal Effect of Bariatric Surgery
Increases GLP1
Decrease in fasting Ghrelin
levels
Increase in fasting and post
prandial PYY
Ghrelin = Hunger
PYY = Satiety
Therefore Bariatric Surgery….
Reduces Hunger
Improve Satiety
Improves Insulin Sensitivity
Prevents hepatic production of glucose

36. Predicted Weight Loss RNY Gastric Bypass Sleeve Gastrectomy
70% Excess Weight Loss
60-65% Excess Weight Loss
Current Weight – Ideal Weight (BMI 24.9) = Excess Weight
How to calculate your expected weight loss (EWL)
Excess Weight x .70 = Expected Weight Loss
How to calculate pts new weight
Current Weight – EWL = New Weight After Surgery
40 y/o Male 5’10” 350 lbs BMI 50.2
350 (CW) – 174 (IBW) = 176 (EW) × .70 % = (EWL)
Anticipated end weight lbs 32.5

37. Nutritional Differences: Bypass Vs. Sleeve
Dumping Syndrome: Bypass Only
Early dumping or Late dumping
The result of poor food choices – refined sugars, simple carbohydrates, excess fats, fried foods
Symptoms:
Sweating, flushing, tachycardia, abdominal fullness, nausea, diarrhea, difficulty concentrating, hunger, fullnes
No Dumping with Sleeve
Sleeve may worsen GERD

38. Supplementation after Gastric Bypass and Sleeve Gastrectomy
Multivitamin and Mineral Supplement
2/day
18 mg of iron, 400 mcg of folic acid, selenium, copper and zinc
Calcium
1500 mg per day
Calcium citrate preferred
Vitamin B12
500 mcg daily
Vitamin D
3000 international units a day

39. Bariatric Surgery “Rules of the Tool”
Eat 3 meals with 1 to 2 snacks daily
Consume grams protein daily through food and protein shakes
Take minutes to eat meal
Chew food well
Focus on eating your meals without distractions
Avoid difficult to tolerate textures
Avoid high fat and/or high sugar food
Avoid simple carbohydrates
Use moist cooking methods
Take supplements daily
Stay hydrated
Regular physical activity

40. Rules of the Tool: Know the “NO’s”
NO eating and drinking at the same time
Separate liquids and solid by 30 minutes
No caffeine for 3 months after surgery
No carbonations
NO NSAIDS
NO alcohol for the first year following surgery

41. Questions?