1. Obesity – Growing epidemic Center for Disease Control and Prevention 2006

2. Obesity – Growing epidemic 65% Americans overweight or obese 30-40% Americans are obese (~100 million) – Doubled in past 20 years – Tripled in past 30 years

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

4. Obesity Trends* Among U.S. Adults BRFSS, 1986 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

5. Obesity Trends* Among U.S. Adults BRFSS, 1987 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

6. Obesity Trends* Among U.S. Adults BRFSS, 1988 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

7. Obesity Trends* Among U.S. Adults BRFSS, 1989 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

8. Obesity Trends* Among U.S. Adults BRFSS, 1990 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

9. Obesity Trends* Among U.S. Adults BRFSS, 1991 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

10. Obesity Trends* Among U.S. Adults BRFSS, 1992 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

11. Obesity Trends* Among U.S. Adults BRFSS, 1993 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

12. Obesity Trends* Among U.S. Adults BRFSS, 1994 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

13. Obesity Trends* Among U.S. Adults BRFSS, 1995 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

14. Obesity Trends* Among U.S. Adults BRFSS, 1996 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19%

15. Obesity Trends* Among U.S. Adults BRFSS, 1997 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

16. Obesity Trends* Among U.S. Adults BRFSS, 1998 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

17. Obesity Trends* Among U.S. Adults BRFSS, 1999 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

18. Obesity Trends* Among U.S. Adults BRFSS, 2000 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

19. Obesity Trends* Among U.S. Adults BRFSS, 2001 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

20. (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) Obesity Trends* Among U.S. Adults BRFSS, 2002 No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

21. Obesity Trends* Among U.S. Adults BRFSS, 2003 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

22. Obesity Trends* Among U.S. Adults BRFSS, 2004 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

23. Obesity Trends* Among U.S. Adults BRFSS, 2005 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

24. Obesity Trends* Among U.S. Adults BRFSS, 2006 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

25. Obesity Trends* Among U.S. Adults BRFSS, 2007 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

26. Obesity Trends* Among U.S. Adults BRFSS, 2008 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

27. Obesity Trends* Among U.S. Adults BRFSS, 2008 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

28. Obesity Trends* Among U.S. Adults BRFSS, 2008 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% Among U.S. Veterans, the prevalence of obesity may be as high as 75%

29. United States 65% Australia 59% Russia 54% United Kingdom 51% Brazil 36% China 15% Overweight

30. Europe >50% are overweight 30% BMI>30 kg/m2 10% BMI>40 kg/m2 Rizzello et al., Obes Surg 2010; 20:55

31. Obesity – Growing epidemic National Health and Nutrition Examination Survey (NHANES) Obesity data 2007-8 compared to data 1999-2006 First trend toward plateau: Flegal KM et.al., JAMA 2010; 303(3)

32. Obesity – Growing epidemic National Health and Nutrition Examination Survey (NHANES) Obesity data 2007-8 compared to data 1999-2006 First trend toward plateau: Flegal KM et.al., JAMA 2010; 303(3) GOOD NEWS?!

33. Obesity – Health impact

34. Comorbid conditions – Type 2 diabetes/Insulin resistance – Cardiovascular disease – Hypercholesterolemia, Hyperlipidemia – Hypertension – Osteoarthritis – Cancer – Liver disease (nonalcoholic steatohepatitis) – Obstructive sleep apnea

35. Obesity – Health impact Type 2 DM Normal BMI

36. Obesity – Health impact Type 2 DMCAD Normal BMI

37. Obesity – Health impact Type 2 DMCAD Hypertension Normal BMI

38. Obesity – Health impact Type 2 DMCAD Hypertension Osteoarthritis Normal BMI Must A, et.al., JAMA 1999:1523

39. Obesity – Health impact Mortality from all causes increases with BMI Adams KF, et.al., NEJM 2006; 355:763

40. Obesity – Health impact Schauer, D. P. et al. Arch Surg 2010;145:57

41. Obesity – Health impact Years of Life Lost—BMI and Age Men Women Fontaine KR, JAMA 2003; 289:187

42. Obesity – Health impact In both men and women, BMI is associated with higher rates of death due to Cancer – Esophagus – Colon/Rectum – Liver – Gallbladder – Pancreas – Kidney – Non-Hodgkin’s lymphoma – Multiple myeloma Calle EE et.al., NEJM 2003; 348:1625

43. Obesity – Health impact --Men and women with BMI>40 kg/m 2 had death rates from all cancers that were 52% (men) and 62% (women) higher than the rates in normal weight individuals. - Risk of mortality from cancer according to BMI (for men) Calle EE et.al., NEJM 2003; 348:1625

44. Obesity – Health impact Risk of Pancreatic Cancer --Obesity in early adulthood  greater risk of pancreatic cancer and a younger age of disease onset Li et.al., JAMA 2009; 301:2553

45. Obesity – Economic burden

46. Overweight and obesity account for nearly 10% of total U.S. medical expenditures >$100 billion Morbid obesity associated with >$11 billion direct health care costs Center Disease Control and Prevention 2009

47. Obesity – Economic burden Obesity-attributable direct medical costs, by state Center for Disease Control & Prev State Millions $

48. Obesity – Economic burden Obesity-attributable direct medical costs, by state Center for Disease Control & Prev State Millions $ California: $7.7 Billion

49. Obesity – Economic burden Mean per capita annual health care expenditure BMI 20-24.9 Dollars 25-29.930-34.935-39.9>40 $2,127 $2,358 $2,873 $3,058 $3,506 Women aged 25-34 Wee et.al., Am J Public Health 2005

50. Surgical Treatment of Morbid Obesity

51. Rationale: – Significant and durable weight loss – Improvement/Resolution of co-morbid conditions – Decrease mortality – Improved quality of life

52. Significant and durable weight loss NIH Consensus Development Conference: “Severe obesity is a chronic, intractable disorder…Surgical procedures [Bariatric Operations] are capable of inducing significant weight loss and amelioration of most of the co-morbid conditions that have been studied.”

53. Significant and durable weight loss Meta-analysis 22,000 patients Variable duration of follow-up Total Percent Excess Weight Loss = 61% 47.5% Adjustable gastric band 61.6% Gastric bypass 70.1% Biliopancreatic diversion Buchwald H et.al., JAMA 2004;292:1724

54. Significant and durable weight loss 10-year post-operative follow-up: %EWL = 54-67% (All bariatric operations) O’Brien et.al., Obes Surg 2006;16:1032 Sjostrom L et.al., NEJM 2007;357:741

55. Significant and durable weight loss 10-year post-operative follow-up: %EWL = 54-67% (All bariatric operations) O’Brien et.al., Obes Surg 2006;16:1032 Sjostrom L et.al., NEJM 2007;357:741

56. Significant and durable weight loss Medical Treatment: Prospective, randomized trial 1-year follow-up Stefanick et.al., NEJM 1998;339:12 Weight loss method (No. patients)Weight Loss Exercise alone (43 patients)0.4 kg Diet alone (46 patients)2.7 kg Diet + Exercise (43 patients)3.1 kg

57. Significant and durable weight loss Medical Treatment: Double-blind placebo-controlled trials + >1-yr follow-up Padwal et.al., Cochrane Database, Issue 4, 2009 AgentMechanism of Action Number of Patients Total Weight Loss OrlistatFat malabsorptio n 10, 6312.9 kg RimonabantAnorectic6,3654.7 kg SibutramineAppetite Supressant 2,6234.2 kg

58. Significant and durable weight loss Medical Treatment: – There is no reliable, durable medical treatment of morbid obesity. – Nearly all patients (95-97%) regain most or all of the weight that was lost within 2-5 years following diet or drug treatment. – Average amount of weight loss is relatively small (2-10% of Excess Weight Loss)

59. Bariatric operations performed in the U.S. (1992-2007) 16,200 205,000 Significant and durable weight loss

60. Improvement of Co-morbid Conditions

61. Effect on Hypertension

62. Improvement of Co-morbid Conditions Effect on Obstructive Sleep Apnea

63. Improvement of Co-morbid Conditions Effect on Type 2 Diabetes

64. Improvement of Co-morbid Conditions Meta-analysis -- 135,246 patients TotalGastric Banding GastroplastyGastric bypass BPD/DS % EWL55.946.255.559.763.6 % resolved overall 78.156.779.780.395.1 % resolved <2 yrs 80.355.081.481.694.0 % resolved >2 yrs 74.6 58.377.570.995.9 Buchwald H et al., Am J Med 2009;122:248

65. Bariatric Surgery – Life Expectancy

66. ReferenceFollow-up Duration Decrease in Mortality MacDonald et.al. 9 years88% Flum et.al. 4.4 years33% Christou et.al. 5 years89% O’Brien et.al. 12 years73% Sowemimo et.al. 4.4 years50% Adams et.al. 7.1 years40% Sjostrom et.al. 14 years31% Sjostrom L et.al., NEJM 2007;357:741 MacDonald et.al., J Gastrointest Surg 1997; 1:213-220 Flum et.al., JACS 2004;199:543 O’Brien et.al., Obes Surg 2006; 16:1032-1040 Sowemimo et.al., Surg Obes Relat Dis 2007; 1:73-77 Christou et.al., Ann Surg 2004;240:416 Adams et.al., NEJM 2007; 357:753-761

67. Bariatric Surgery – Life Expectancy Adams et.al., NEJM 2007; 357:753-761 Retrospective study comparing 7,925 patients who had gastric bypass vs. 7,925 patients severely obese controls. Matched for age, sex, BMI Mean f/u = 7.1 years Cause of death RYGB vs. Car drivers p-value All mortality40% decrease <0.001 CV disease56% decrease 0.54 All cancers60% decrease <0.001 Diabetes92% decrease <0.005

68. Bariatric Surgery – Life Expectancy Schauer, D. P. et al. Arch Surg 2010;145:57 Years gained – BMI and Age 1. Every age group benefits, women and men. 2. The greatest benefit is in the younger population. 3. For any age, the greatest benefit is in the heaviest population.