Slide set for Workshop 2 Complex Obesity Cases Acknowledgments C Hughes

WORKBOOK PAGES Workshop 2 Complex Obesity Cases

Review incidence of complex obesity Look at recommended clinical pathways Review the options available for treatment Case discussions Aims

A recent systematic review (Tsai et al) noted the disproportionate economic burden associated with severe and complicated obesity. 15% of obese population have severe obesity but account for 35% of the total obesity costs. NICE CG 189 recommends Offer referral to a Tier 3 unit for treatment Consider bariatric surgery if BMI >40 kg/m2 or > 35kg/m2 with co-morbidities. Bariatric surgery treatment of choice if BMI>50 kg/m2 Severe obesity BMI >40 kg/m2 is the fastest growing category of obesity

Obesity services 2013 Dept of Health

Public health interventions and Tier 2 services are cost- effective for many people Tier 3 services must integrate fully into the obesity pathway Aim is to improve health by losing weight and making permanent modifications to habits and behaviour to support weight maintenance and a healthy lifestyle Multi-disciplinary team for complex patients Bariatric surgery is an appropriate outcome for some patients Tier 3 services - part of a pathway

Multicomponent medical service offering dietary and activity advice, pharmacotherapy, psychological therapy, VLCD, and assessment and preparation for bariatric surgery in line with NICE guidance (CG ) Specialist equipment and on-site gym Individual monthly appointments plus group interventions High degree of patient participation Monthly patient led support group post discharge Facebook support group (patient run) Research Active Description of Tier 3service Italics - specific for Fakenham Weight Management Service

Dedicated administrator General Practitioner with specialist training (SCOPE certification) or Endocrinologist/bariatric Physician Obesity specialist nurses (OSNs) Dietician Psychologist or Psychologically trainer practitioner Health trainer Exercise professional/physiotherapist Occupational therapist Also clinical core group including endocrinologist, clinical psychologist, Public health, patient representatives x3, and CCG representative Multi-disciplinary Team Italics - specific for Fakenham Weight Management Service

Mrs A is 46 year old carer and has struggled with her weight for many years. She now has degenerative changes to her L knee which is affecting her home and working life. Orthopaedic team will not operate until BMI 30kg/m2. She was only concerned about her knee pain and her job, and was not very interested in bariatric surgery. Examination; no signs of endocrine abnormality. It was noted that both arms were significantly scarred. PMH; Asthma, depression and self-harm, impaired fasting glycaemia. Medication; Naproxen 500mg bd, Co-dydramol 8 a day Case One

What would you want to know about Mrs A with regard to her ‘weight history’? Would you want to know more about her mental health? And why? What first-line bloods would you arrange? What would you consider to help her lose weight? What do you think about the orthopaedic surgeons setting a BMI target? Discussion points

She was put on LELD and lost around 20kg, her knee pain resolved and she was able to stop all painkillers. She was discharged to her GP at 129kg, on orlistat for further support to continue to lose weight, or maintain weight loss. 2 years after discharge her weight was 145kg Discussion point: should she have been referred for bariatric surgery after her initial weight loss? Case 1 actual result

Mr C, 41 year old man Seen at a regional bariatric surgery centre in the previous year but he then declined surgery at the last minute. Initial weight: kg, BMI 50.4 kg/m2. He lives with his disabled wife and young family. He was previously a farm worker, now unemployed. Sits at home playing games on computer all day. Examination; no signs of endocrine disease, normal heart sounds PMH; Severe obstructive sleep apnoea, OA feet/hands. Medication; Nil Case 2

At his first appointment how would you explore Mr C’s expectations for weight loss and his motivation? How could you motivate Mr C to become more active? Mr C has severe sleep apnoea. What is its relevance? What blood tests would you want to arrange prior to referring a patient for bariatric surgery? What other information might the surgical centre require? Discussion points

He lost about 3 kg with intensive support from specialist nurses and dietitian He did not tolerate LELD Hard to get him more physically active Psychological therapist and team persuaded him that surgery would help him Laparoscopic gastric bypass 2014 Excellent weight loss and no complications Current weight 83.8kg BMI 26.5 kg/m2 Mood improved and fit to work Case 2 actual result

Mr D, 55 year old ex-smoker, T2D since 2006 and OSA Car breakdown repair man. Normal weight most of his life and was sporty, weight increased over the last years,12kg weight gain in last year Initial weight 139kg BMI 42.9 kg/m2. Does not attend appointments for T2D or OSA. No hypo’s but he often omits his morning insulin. Changes his insulin dose on his own rules Often misses breakfast, then has brunch fry up, followed by ‘garage food’ but eats better at home Interested in bariatric surgery as he ‘wants his life back’ HBA1c 79mmol/l No diabetic nephropathy, normal FBC and renal function, cholesterol 6.7 Examination; chronic left leg ulcer, decreased vibration sense ankles, abdominal striae. PMH; OSA - was on CPAP but he has discontinued, Severe OA both knees and ankles Spinal surgery - L4/5 laminectomy 2006 followed by DVT Medication; 200IU lantus insulin bd, Liraglutide 1.2mg daily, Gliclazide 80mg x4 daily Case 3

What are the medical issues that need addressing, and how do you start? What dietary advice would be appropriate? Is he a suitable candidate for bariatric surgery? How would you counsel him about bariatric surgery? Discussion points

Case 3 – initial outcome Attended for one year Discussion of health risks and benefits of losing weight Individual sessions with psychological therapist Dietary advice from dietitian and OSN Individual appointment with medical exercise specialist Bariatric physician appointments x4 Advised to attended respiratory and diabetic appointments regularly He decided against bariatric surgery

Case 3 - final result Weight loss 28.3 kg (19.9%) Final BMI 33.2 kg Leg ulcer healed Insulin reduced to 35 U daily Walking 2 miles a day Wife says no snoring Attending long-term support group Agrees to attend diabetic review appointments