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Obesity in Canada 1 in 5 adults are obese

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Presentation on theme: "Obesity in Canada 1 in 5 adults are obese"— Presentation transcript:

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

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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

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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?


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