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Obesity: prevalence, influences and challenges
Canadian Medical Association recognizes obesity as a chronic disease (October 2015).
Source: Katzmarzyk PT, Mason C. Prevalence of class I, II and III obesity in Canada. CMAJ. 2006 Jan 17;174(2):156-7.
4-fold increase in morbid obesity
over the last 20 years
4-fold increase in morbid obesity
over the last 20 years
80-90% of patients with T2DM overweight or obese*
Some antihyperglycemic therapies contribute to weight gain
Higher BMI increases mortality
Modest weight loss (5-10% total body weight) can improve metabolic parameters
*Wing RR. Weight loss in the management of type 2 diabetes. In: Gerstein HC, Haynes B editor(s). Evidence-Based Diabetes Care. Ontario, Canada: B.C. Decker, Inc, 2000:252–76.
Interdisciplinary weight management programs to prevent weight gain and achieve and maintain a lower, healthy body weight (Grade A, Level 1A).
Recognize the effect of anti-hyperglycemic agents on body weight. (Grade D, consensus).
Bariatric surgery may be considered when lifestyle interventions are inadequate in achieving healthy weights in patients with type 2 diabetes and class II or III obesity (Grade B, Level 2).
*A.Sharma and D. Lau (2013). Weight Management in Diabetes. Can J Diabetes 37: S82-S86.
Weight management is not a simple equation
Goals around weight management:- Preventing weight gain- Preventing weight regain- Understanding best weight
Weight Management Strategies
Age ≥ 18 years
Body Mass Index (BMI) ≥ 40
BMI ≥ 35 with significant co-morbidities
Heart disease, Type 2 diabetes, Hypertension, Sleep Apnea, GERD
History of prior weight management attempts
Motivation and engagement in lifestyle modifications* Ontario Bariatric Network
Active substance use, including nicotine and alcohol, <6 months prior to surgery.
Medical or surgical conditions that may make surgery a high risk to perform.
Severe or poorly controlled current psychiatric illness or undertreated symptoms.
* Ontario Bariatric Network
NSAIDS are contraindicated for gastric bypassSignificantly increased risk of GI bleeding
Avoidance (pre / post op) : nicotine, caffeine Potential detrimental effect on anastomoses and GI lining
Weight loss 52-77% excess body weight loss maintained at 10 yrs
All cause mortality lowered 29-40%CAD 49%, cancer 60%
Diseases improved or remission (60-80%)Diabetes, lipids, BP, liver disease, MSK pain Sleep apnea resolves 95%
Improved Quality of Life TD Adames et al. (2007). Long-term mortality after gastric bypass surgery. N Engl J Med. 357: 753-761.
Impressive outcomes:
Metabolic – STAMPEDE trial of 150 moderately obese patients showed that 42% of patients with RNY had A1C < 6% compared to 12% of a medical therapy group
Metabolic outcomes are independent of weight loss
Reduced truncal fat and increased beta cell function
Improved insulin sensitivity
Reduction / elimination of medications: insulin, oral antihyperglycemics, antihypertensives, statins
ALL surgeries have a risk of death
Studies show 0.2-2.0% mortality for RYGB<2 deaths per 100 operations
The most common causes of death:Pulmonary embolism (blood clot in the lung)Leak in staple lines made during surgery
Nausea / VomitingDiarrhea / DumpingHeart and lung problemsBlood ClotsStrictureBlockageLeaksInfectionOrgan failureDeath
ConstipationNutrient deficienciesProtein malnutritionHair lossGallbladder diseaseMental health problems
Early complications Later complications
Higher incidence of post prandial hypoglycemia post bariatric surgeryCan occur months to years after surgeryCauses related to rapid transit of food between stomach and small intestineCarbohydrates absorbed much quicker producing an acute spike in glucose provoking a strong hyperinsulinemia.Responsive to dietary modification with small frequent low carb mealsSome patients require medical therapy such as acarbose to reduce carbohydrate absorptionMore severe cases require partial pancreatectomy.
Lifestyle and weight management
• Understanding influences on weight management
• Encourage awareness and application of healthy behaviours
• Building confidence in managing lifestyle change
• Accepting best weight
Emotions & Coping Strategies
Sleep
Biology, hormones + more
Medications
Weight loss andweight cycling
Mental Health
Portion Management Disorganized eatingBeverage
Consumption
Understanding nutrients and Inadequacies
Environments: family, work, social
Planning and Goal Setting
Plate method Nutrient Supplements
Mindful Eating Physical Activity
Balanced plate Balanced plate after bariatric surgery
Compromised: food and fluid volumes, nutrient absorption, surface area
Risks: nutrient deficiencies, appetite irregularity, disorganized eating, absorption
Diet progression•5 stages•Progress to normal diet
Nutrient supplements•Multivitamin-mineral•Vit B12, Vit D, Calcium citrate•Others
Lifelong lifestyle •Mindful•Coping•Accepting
Ideal Body Weight
Best Weight
Desired Body Weight
Weight will continue to change through the course of our life.
Bariatric Surgery shows the greatest total weight loss even over years of follow-up.
Wadden TA, Foster GD Med Clin North Am 2000: 84(2) 441-461, vii. Review
Self- monitoring
Mindfulness
Journaling
Problem Solving/Goal
Setting
Motivational Techniques
Manage Stress
Social support
Supported by the Ministry of Health and Long-Term Care and South East Local Health Integration Network
Only bariatric assessment service between Ottawa and Toronto
Means easier access to care closer to home
Committed to providing patient and family centered care for obese and morbidly obese patients
Provide pre-surgical assessment and post surgical follow-up services
Surgeries performed at Toronto East General Hospital and St. Michael’s Hospital
Medical LeadProgram Manager2 Nurse Practitioners1 Registered Nurse3 Registered Dietitians (1 FT, 0.8 FT, 0.5 PT)2 Social Workers 3 Medical Secretaries / Data Coordinators
Referral to Bariatric Registryfrom Family Doctor/Nurse Practitioner
Referral received by RATCPackage mailed to patient
Orientation SessionPatient questionnaire returned
Patient Questionnaire Deferred from RATC
Initial Assessment Baseline Bloodwork Booked with Dietitian Tests ordered as applicable and Social Worker
Referred for further medical/psychiatric
evaluation
Transfer to surgical site
Required attendance at orientation session
Patient to make informed decision about continuing the process
Pre-operatively patients assessed by each member of the team
Required to complete tests relevant to their pre-surgical screening
Follow-up includes multiple visits with team members starting at 1 week post-operatively
Follow-up at 1,3,6,9, and 12 months
Support groups offered bi-weekly
Annual follow-up for 5 years
Glycemic Optimization Clinic:•Provides support to pre-op bariatric candidates with elevated blood glucose levels•Endocrinologist and CDE support once weekly
Surgical/General Medicine Clinic:•Dr. Robertson providing consultation to complex bariatric surgical patients once monthly
Sleep Apnea Assessment/ Respirology clinic•Dr. Aaron Aggarwal providing support for pre-operative bariatric patients requiring sleep study assessment
Internal Medicine Clinic•Clinics run weekly•Optimize patients’ chronic health conditions
Ontario Bariatric Network (OBN) :
http://www.ontariobariatricnetwork.ca/
Public Health Agency of Canada (2011). Obesity in Canada. Accessed at https://secure.cihi.ca/free_products/Obesity_in_canada_2011_en.pdf
Mechanick et al (2013) Clinical practice guidelines for the Perioperative Nutritional, Metabolic and Nonsurgical support of the bariatric surgical patient. Surgery for Obesity and Related Diseases. 9: 159-191.
Isom et al (2014). Nutrition and Metabolic Support Recommendations for the Bariatric Patient. Accessed online at www.ncp.sagepub.com
Ontario Bariatric Network www.ontariobariatricnetwork.ca
Canadian Obesity Network www.obesitynetwork.ca
