1. Riverside Medical and Surgical Weight Loss Center David Salzberg, M. D
Riverside Medical and Surgical Weight Loss Center David Salzberg, M.D., Bariatric Surgeon Felice Haake, D.O., Medical Bariatrician

2. 60% (34 million) of Americans are overweight

3. 25% of American children are overweight

4. 6% of health care expenditures ($238 billion / year)

5. Obesity Trends* Among U.S. Adults BRFSS, 1985
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% %–14%

6. Obesity Trends* Among U.S. Adults BRFSS, 1992
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% %–14% %–19%

7. Obesity Trends* Among U.S. Adults BRFSS, 1999
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% %–14% %–19% ≥20%

8. Obesity Trends* Among U.S. Adults BRFSS, 2006
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% %–14% %–19% %–24% %–29% ≥30%

9. Obesity Trends* Among U.S. Adults BRFSS, 2009
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% %–14% %–19% %–24% %–29% ≥30%

10. Economic….. National cost = $200 billion $93 Billion in medical bills
$33 Billion on weight-loss products
$74 Billion in “Absenteeism”
Obesity can impact different areas of your life.
Some overweight people have reported that they have had trouble getting a job. Others feel that people make judgments about their character based on their weight. It appears obesity is the last acceptable form of social discrimination.
Obesity impacts our nations economy by increasing medical related costs and causing employees to miss work because of health reasons. You may find that your personal expenses have also increased due to prescription drugs, money spent on weight loss products or other of pocket medical costs.
Perhaps most importantly, obesity will effect your health. For many years, scientists and doctors have known that obesity is a health risk. Other well-known health risks include smoking and heavy drinking. Until recently, however, no one knew whether one of these problems was any riskier than the others. A recent study compared obesity with other known health risks: smoking, heavy drinking, and poverty, and reported that obesity is the most serious problem.* In fact, the increase in health problems due to obesity is similar to what is seen in 20 years of aging.
*Highlights of the results of this study are available at

11. The Personal Cost of Obesity
Change in the cost of living after
weight-loss surgery can be dramatic
ITEMS
Estimated Annual Costs
Mean medical/drug costs (BMI  35)1
$ 5,965
Out-of-pocket healthcare expenses2
$ 2,182
Employment inactivity costs3 $
Commercial weight loss program fees4 $
Prescription co-pays (5 meds at $10)
Grocery and dining costs5
$ 5,321
TOTAL
$15,568
Despite the benefits of loosing weight, some people worry about being able to pay for LAP-BAND surgery. But what most people don’t realize is just how much is costs to be seriously overweight. Between the costs of medication, doctor visits, groceries and weight loss program fees your weight can cost your over $15,000 a year. We know that better health and emotional satisfaction are priceless benefits, but loosing weight can dramatically lower your cost of living expenses.
References: 1. Health Management Research Center, University of Michigan, 2001; 2. U.S. Bureau of Labor Statistics, Consumer Expenditures in 2001; 3. Source: Colditz, GA. “Economic costs of obesity and inactivity,” Med Science Sports Exercise, 1999; 4. Marketdata Enterprises, Inc., 10/02; 5. U.S. Bureau of Labor Statistics, Consumer Expenditures in 2001

12. 300,000 deaths annually

13. Prevalence of Medical Co-Morbidities Attributable to Obesity
Sources: Bariatric Surgery: A Summary of the Literature, 1990 to 2001

14. Relative Risk of Cancer - Men

15. Relative Risk of Cancer- Women

17. A typical fast food meal
Big Mac: kcal
Large Fries: kcal
32 0z (large) soda: kcal
TOTAL kcal
A 70 kg moderately active man requires kcal/day (3 meals).

18. Where Do Patients Fit In?
Clinical Terms Used to Describe Various Levels of Body Fat
Normal Weight (BMI 18.5 to 24.9)
Overweight (BMI 25 to 29.9)
Obese (BMI 30 to 34.9)
Severely Obese (BMI 35 to 39.9 )
Morbidly Obese (BMI 40 or more)
The ideal BMI ranges from 19 to 25. If your BMI is between 25 and 29.9, you are thought to be overweight. If it is between 30 and 39.9, you are obese. If your BMI is 40 or more, you are said to have morbid obesity.
The term “morbid” obesity is used because this degree of excess weight may considerably reduce life expectancy and is associated with an increased risk of developing conditions or diseases such as diabetes, high blood pressure, joint problems, gallstones, stroke, heart disease, and psychosocial problems.

19. Weight Loss at RRMC
Medical
Surgical
Behavioral

20. Weight Loss Options (Moderately Overweight)
Medical Treatment of Obesity
Diet
low in calories, fat and carbohydrates
Exercise
40 minutes 5 times per week
Behavior Modification
eat 3 sensible meals per day, avoid snacking, meal replacement
There are several options for treating obesity. The most common approaches for losing weight are diets, exercise and weight loss drugs. Studies show that diets and weight loss aids rarely work in helping severely overweight people reach the goal of long-lasting weight loss while professionally supervised diets that include prescription drugs show an average loss of only 6-9% of excess body weight.

21. Two Options Accelerated Weight Loss
The use of pre-packaged meal replacements and supplements to achieve fast results.
Lean&Clean
A whole foods approach to weight loss and lifelong health.

22. Where Do Patients Fit In?
Clinical Terms Used to Describe Various Levels of Body Fat
Normal Weight (BMI 18.5 to 24.9)
Overweight (BMI 25 to 29.9)
Obese (BMI 30 to 34.9)
Severely Obese (BMI 35 to 39.9 )
Morbidly Obese (BMI 40 or more)
The ideal BMI ranges from 19 to 25. If your BMI is between 25 and 29.9, you are thought to be overweight. If it is between 30 and 39.9, you are obese. If your BMI is 40 or more, you are said to have morbid obesity.
The term “morbid” obesity is used because this degree of excess weight may considerably reduce life expectancy and is associated with an increased risk of developing conditions or diseases such as diabetes, high blood pressure, joint problems, gallstones, stroke, heart disease, and psychosocial problems.

23. Challenge with Medical Therapy
Rebound

24. Problems with Conservative WL in Morbidly Obese
Most patients (95-97%) regain most or all of the weight that was lost within 1 year following diet or drug treatment
The average amount of weight loss is relatively small pounds
Drug therapy may be associated with severe complications (Fen-Phen and heart disease)

25. Weight Loss Surgery
Average 55% loss of excess body weight OVER LIFETIME

26. Surgery for morbid obesity? Why?
Calories OUT must be > Calories IN
Restrict
Malabsorb

27. Most Common Surgical Options
Gastric Bypass (GBP)
Sleeve Gastrectomy
Band System
The two most common obesity surgeries in the United States are the Gastric Bypass (GBP) and the LAP-BAND System.
The Gastric Bypass is both a restrictive and malabsorptive operation. With this procedure, the stomach is stapled to make a smaller pouch, then a part of the intestines is attached to it. The result is that you cannot eat as much, and you absorb fewer nutrients and calories from your food. The changes in your stomach and intestine are permanent.
The LAP-BAND System is a restrictive and adjustable procedure. During surgery the LAP-BAND is placed around the upper part of the stomach to create a new tiny stomach pouch. As a result, patients experience an earlier sensation of fullness and are satisfied with smaller amounts of food. There are no permanent changes made to your stomach or intestines and the LAP-BAND can be adjusted through an access port below the surface of the skin.
Restrictive and Malabsorptive
Restrictive
Restrictive and Adjustable

28. Gastric Bypass (Roux-en-Y) (43644)

29. LAGB Procedure (43770)
The name “LAP-BAND” comes from the surgical technique used (laparoscopic, or “keyhole,” surgery) and the name of the product used (gastric band). The LAP-BAND System is the only FDA approved weight-loss surgery available and since it’s inception there have been over 200,000 placed world wide.
During the LAP-BAND System procedure, instruments are placed through very small incisions. The LAP-BAND is fastened like a wrist watch around the upper part of the stomach to create a tiny new stomach pouch. There is no cutting or stapling of the stomach needed in this procedure.
The LAP-BAND is connected by tubing to an access port placed under the skin during surgery. Later the surgeon can adjust the LAP-BAND with saline through the access port.
With the LAP-BAND the food you eat moves slowly from the small upper pouch, past the elastic band, and on to the lower part of your stomach, where it is digested normally. As a result, you eat less food and feel full faster.

30. Sleeve Gastrectomy (43775)

31. Bariatric Patients at RRMC

32. Preop Workup Information Session (Free, group or private)
Initial Bariatric Consultation (Level 5 Visit)
Labs and Imaging
Forward to Insurance Carrier

33. Candidacy? BMI criteria Are at least 18 years old
BMI is at least 40
BMI is at least 35 and with combormidities
Are at least 18 years old
Understand surgery and the risks
No uncontrolled psychological conditions
Are prepared to attend regular follow-up sessions and make lifestyle changes
Consensus of the bariatric team
The LAP-BAND System is not right for everyone. You and your surgeon should work together to decide if it is the right treatment for you. Here are some of the things your surgeon will consider.

34. Insurance Varies by insurance company
Varies by patients choice of plan
Many large corporations on Peninsula offer coverage
Center employs coordinator/insurance specialist who will assist

35. Insurance Approval This is often the biggest delay!
Requirements and lead time vary by company
Sufficient documentation of medically supervised diet

36. Finance Programs Credit Lines through Riverside
Your practice must be enrolled in the LAP-BAND System Finance Program. Contact your sales representative for information on how to enroll.
Once you are qualified for the procedure you can call INAMED’s toll free number to use a free consulting service; LAP-BAND option 4. They will connect your with a lender who will assess your individual financial situation to help secure a loan that matches your needs. The participating lending institutions have competitive interest rates and are large companies focused on funding the LAP-BAND system procedure only. They will not finance Gastric Bypass. While a loan is not guaranteed, the lenders will offer you a variety of secured and unsecured financing options which result in a higher loan approval ratio. Most loans are approved within 1 to 2 business days and funded within 5 to 15 business days.
On April 2, 2002, the Internal Revenue Service (IRS) announced a change in its policy regarding how taxpayers may deduct the costs of weight loss or weight control programs.
According to the new policy (Revenue Ruling ), “obesity is medically accepted to be a disease in its own right,” so a taxpayer can now claim weight loss expenses as a medical deduction. Prior to this new ruling, the taxpayer could only include in medical expenses the cost of a weight loss program undertaken at a physician’s direction to treat an existing disease (such as heart disease).

37. RMWLC Requirements
Helpful to have all paperwork regarding past weight loss attempts from PCP
Initial questionnaire

38. Patient Flow- Inpatient
To Operating Room
Walking night of surgery
Drinking day after surgery
Home POD 2
Back to work in less than two weeks

39. Possible Risks and Complications
Remember: There are risks associated with any surgery.
Categories
LAP-BAND
Gastric Bypass
Sleeve Gastrectomy
Major Complications
0.2%
1.4%
Mortality Rate
0.11%
0.5%
0.8%
Prospective study on lap bariatric procedures with complications categorized using Clavien’s methodology (Clavien P. Proposed classification of complications of surgery with examples of utility in cholecystectomy. Surgery 1992; 111: ) for severity scores.
Grade 3 and 4 are considered “major.”
Grade
Definition
LAP-BAND
RYGB
BPD 1
Events carrying minor risk
IV for hydration, hospitalized for nausea 2
Events requiring drug therapy, transfusions, hospital stay > 2x median stay
Prolonged LOS for post-op edema
Leak managed with TPN, PE
Pancreatis, delayed gastric emptying 2b
Events requiring endoscopy or reop (not requiring organ resection)
Port or band revision
Reop for bleeding, exploratory lap 3
Events with lasting disability or requiring organ resection
Sigmoid esophagus
Revision of anastomosis, bowel resection 4
Death
Sources: Ren CJ, Laker S, Weiner M, Hajoseuedjavadi O, J Am Coll Surg, v 202, No 2, Feb 2006; ASERNIPS Executive Summary, 2002.

40. Mortality Mortality Rate Rate (%) 2.00 1.50 1.00 0.50 0.00
Drug Eluding Stent4
Mortality Rate
Lap Cholecystectomy4
0.00
0.50
1.00
2.00
Rate (%)
Appendectomy4
GI Obstruction4
CABG w/ cath4
Carotid Stent4
Hernia4
Flum1
DeMaria2
Buckwald3
HHS4
1.50

41. Comparing Weight-Loss Results
Gastric Bypass
LAP-BAND
Although initial weight loss with Gastric Bypass is typically very rapid, surgeons report that at 5 years many LAP-BAND and Gastric Bypass patients achieve comparable weight loss results. 55% of excess weight for the LAP-BAND versus 59% with Gastric Bypass.
Source: O’Brien et al. Obesity is a Surgical Disease: Overview of Obesity and Bariatric Surgery, ANZ J Surg, 2004; 74:

42. % Medical Co-Morbidities Resolved after Bariatric Surgery
Sources: Bariatric Surgery: A Summary of the Literature, 1990 to 2001

43. Riverside Medical & Surgical Weight Loss Center
Full service metabolic center, under one roof
Choice of Medical or Surgical options
Dietician, Exercise, Behavioral
Access to diagnostics in same building
Open, Active correspondence with referring provider