Review incidence of complex obesity Look at recommended
clinical pathways Review the options available for treatment Case
discussions Aims
Slide 4
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
Slide 5
Obesity services 2013 Dept of Health
Slide 6
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
Slide 7
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 189 2014) 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
Slide 8
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
Slide 9
Slide 10
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
Slide 11
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
Slide 12
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
Slide 13
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: 159.6 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
Slide 14
At his first appointment how would you explore Mr Cs
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
Slide 15
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
Slide 16
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 10-15 years,12kg weight gain
in last year Initial weight 139kg BMI 42.9 kg/m2. Does not attend
appointments for T2D or OSA. No hypos 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
Slide 17
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
Slide 18
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
Slide 19
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
