Don’t Give up on Your New Year’s Resolution

• Achieving a healthy weight, eating healthier, and exercising more are examples of resolutions that consistently make the top 5 New Year’s resolution every year!

• Where to start???

New Year’s Resolution

• Calories from beverages alone can account for 25% or more of our daily caloric needs

• Eliminate regular soda, sweetened tea, lemonade, fruit juice and sports drinks

• Focus on water

Beverages

430 calories 220 calories

Meals & Snacks• Eating 3 meals daily helps to fuel a healthy

metabolism

• It is harmful to metabolism to skip meals

• Snacks can serve as a fuel source between meals

Meals

Starches• Bread• Pasta• Rice• Cereal• Crackers• Tortillas• Potatoes• Peas• Corn

Protein• Chicken• Beef• Pork• Turkey• Fish• Eggs• Peanut butter• Nuts• Beans/lentils (S + P)

Non-Starchy Vegetables• Broccoli• Cauliflower• Asparagus• Lettuce• Tomatoes• Cucumbers• Peppers• Spinach• Carrots• Mushrooms

Snacks• 1-2 snacks daily may be appropriate to support a

healthy metabolism

• Protein + ½ cup of fruit• Protein + ½-1 cup of vegetables• Avoid/limit “snack foods” such as chips, cookies,

and crackers

Physical activity• Current recommendation is 150 minutes of

physical activity weekly

• Cardiovascular exercise, lifting weights, yoga, Pilates, etc

• Improvement in weight, lipid panels, blood sugar

Tips• Start small• Change one thing at a time• Talk about it• Ask for support• Don’t beat yourself up

Bariatric Surgeon Presentation

Orlando J. Icaza, MD, FACS, FASMBS

Obesity Trends* Among U.S. AdultsBRFSS, 1985

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%



No Data <10% 10%–14%



No Data <10% 10%–14%



No Data <10% 10%–14%



No Data <10% 10%–14%



No Data <10% 10%–14%



No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19% ≥20%



No Data <10% 10%–14% 15%–19% ≥20%



No Data <10% 10%–14% 15%–19% ≥20%



No Data <10% 10%–14% 15%–19% ≥20%



No Data <10% 10%–14% 15%–19% 20%–24% ≥25%



No Data <10% 10%–14% 15%–19% 20%–24% ≥25%



No Data <10% 10%–14% 15%–19% 20%–24% ≥25%



No Data <10% 10%–14% 15%–19% 20%–24% ≥25%



No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%



No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%



No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%



No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%



No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%



No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Prevalence of Self-Reported Obesity Among U.S. Adults by State and Territory

BRFSS Methodological Changes Started in 2011

New sampling frame that included both landline and cell phone households.

New weighting methodology used to provide a closer match between the sample and the population.

Prevalence¶ of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2011

¶ Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be compared to prevalence estimates before 2011.

*Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%.




Prevalence¶ of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2013¶ Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be

compared to prevalence estimates before 2011.








Obesity Facts• 35% OF ADULT POPULATION BMI >30• 6% OF ADULT POPULATION BMI >40• 210 BILLION OF USD ARE SPENT ANNUALLY TO

TREAT CO-MORBIDITIES ASSOCIATED WITH OBESITY (21% OF HEALTH EXPENDITURES)

What is morbid obesity?• Overweight and obesity are defined as abnormal or excessive fat

accumulation that presents a risk to health. (WHO)– BMI provides the most useful population-level measure of

overweight and obesity as it is the same for both sexes and for all ages of adults.

• Categories:– Normal: 19-24.9– Overweight: 25-29.9– Obese: 30-39.9– Morbidly Obese: 40-49.9– Super Morbidly Obese: 50-59.9

NIH GuidelinesWho is a good adult candidate for bariatric

surgery?Bariatric surgery may be an option for adults who have• a body mass index (BMI) of 40 or more, OR• a BMI of 35 or more with a serious health problem

linked to obesity, such as type 2 diabetes, heart disease, or sleep apnea

• a BMI of 30 or more with a serious health problem linked to obesity, for the gastric band only

https://www.niddk.nih.gov/health-information/_layouts/gov.nih.niddk/handlers/redirect.ashx/DictionaryTerm?ListItemId=1130


http://www.niddk.nih.gov/health-information/health-topics/Diabetes/your-guide-diabetes/Pages/index.aspx


The New Vital Sign = BMIBMI = Weight in Kilograms

(Height)m2

% Excess Weight Loss (EWL) = CW – EW _____ x 100%CW – W (BMI 25)

Metabolic Syndrome• Type 2 Diabetes +• Hypertension +• Hyperlipidemia +• ↑ waist circumference (102 cm men; 88 cm females) +• = ↑morbidity and mortality

Obesity Associated with Several Co-Morbid Conditions

• DM2 (8.3% OF POPULATION)• HTN• HYPERLIPIDEMIA• SLEEP APNEA• NAFLD (85%) NASH (25%) CIRRHOSIS (25%)• CAD MI• ATRIAL FIBRILLATION STROKE• CARDIOMYOPATHY CHF

Obesity Associated with Several Co-Morbid Conditions

• GERD• PCOS• OSTEO-ARTHRITIS• INFERTILITY• GALLBLADDER DISEASE• POOR QUALITY OF LIFE• MALIGNANCY

Obesity Current Treatments Lifestyle Changes

Diet Exercise regimen

Traditional lifestyle modification results in 3-7% total body weight loss Those with morbid obesity - 95% regain in 5 years

Pharmacotherapy 10% total body weight with diet + exercise Barriers to cost, compliance, side effects and relapse after stopping

medication Bariatric Endoscopic Therapies Bariatric Surgery

Most durable and substantial

Surgical Options

Reasons contributing to an increase in bariatric surgery

• Prevalence of severe obesity (6% > BMI 40)• Improved public and physician awareness of the

burden of obesity related medical and psychosocial morbidity

• Effectiveness of bariatric surgery• Development of laparoscopic techniques

Optimal Procedure• Low morbidity and mortality• Result in significant and durable weight loss• Lead to improvement and resolution of obesity

related co-morbidities and quality of life

Open incisionOpen incision

Laparoscopic techniqueLaparoscopic technique90-95% of procedures90-95% of procedures

Less Invasive Less scarring Less pain Shorter recovery time Less risk of hernia and

SSI Better visualization

Bariatric Procedures Bariatric Procedures Laparoscopic Adjustable Gastric Band Best

• BMI 30-40• Active• Compliant• Good support/MDT approach• Age 18-60

Bariatric Procedures Bariatric Procedures Laparoscopic Adjustable Gastric Band Procedure Benefits

1. Shorter operative time Easiest to perform

2. No change to anatomy3. Adjustable and/or

reversible/removable4. Reduce risk for micronutrient

deficiencies5. Shorter hospital stay (outpatient)6. Shorter recovery (return to work

1-2 weeks)7. Lowest risk for mortality (0.08%)8. Lower cost

Bariatric Procedures Bariatric Procedures Laparoscopic Adjustable Gastric Band

Procedure Risk • Failure to lose weight

– Slower weight loss (3 years)– Lower overall weight loss

• 40-50% EWL– Cheatable

• Device related problems – Port Leakage– Device slippage– Erosion

• Anatomic and physiologic problems with the device– Nausea/vomiting/abd pain– GERD– Esophageal and pouch dilatation

• Multiple adjustments • Long term tolerance?

– Explantation rate >50% at 5 years; 75% at 15 years• ¾ of the patients require second operation

BariatricBariatric ProceduresProcedures Laparoscopic Sleeve Gastrectomy Best

• BMI 35-45• No GERD or Barrett’s • Active• ↑ Risk/Extremes of age• Adhesions/hernias• Transplant• Stage procedure for BMI > 50

to reduce risk

BariatricBariatric ProceduresProcedures Laparoscopic Sleeve Gastrectomy Procedure Benefits

1. Shorter operative time (40 min) Technically easier to perform

2. Offers good weight loss 50-60% EWL (2-5 yrs)

3. No implanted medical device and no anastamosis or bypass of intestines

4. No risk of marginal ulcers or internal hernias5. Causes favorable changes in gut hormones

affecting long-term hunger and satiety (ghrelin)

6. Pyloris preservation (no risk of dumping or diarrhea)

7. Option for patients with BMI > 60 as a staged procedure

8. May be used as a revisional procedure for recidivism

BariatricBariatric ProceduresProcedures Laparoscopic Sleeve Gastrectomy Procedure Risk

• Long staple line• Irreversible • Durability

– No long-term data

Laparoscopic Gastric Bypass Best• BMI 35-50• Type 2 Diabetes (< 10 years

and not on insulin) • Significant GERD• Barrett’s Esophagus • Age 18-65• No previous stomach and

lower GI/hernia

Bariatric Procedures Bariatric Procedures

Laparoscopic Gastric Bypass Procedure Benefits1. Current Gold Standard

Improvement or resolution of diabetes (>70%)

2. Long-term experience Durable; over 40 yrs.

3. Restrictive & malabsorptive Excellent & durable weight loss (60-75%

EWL) 20-30 cc pouch 100-150 cm alimentary limb 50 cm BPL

4. Acceptable lower risk of malnutrition and malabsortive complications with excellent weight loss benefit


Laparoscopic Gastric Bypass Procedure Risks• Longer operative time

– 60-90 minutes• Longer hospital stay

– 2-3 days • Changes anatomy• Leaks, obstructions, bleeding• Nutritional deficiencies• More difficult to reverse• Dumping syndrome (↑ sweets)• Marginal Ulcers/Strictures/Internal

Hernias• Recidivism 15-20% (↑ for BMI >

50)


BariatricBariatric ProceduresProcedures Laparoscopic Duodenal Switch Best

• High BMI > 50• Poorly controlled Type 2

Diabetes• Hypertriglyceridemia• Metabolic Syndrome • Compliant pts• Polyphagia• Age 18-60

BariatricBariatric ProceduresProcedures Laparoscopic Duodenal Switch

Procedure Benefits1. Greatest reduction in weight (>80% EWL)2. Lowest recidivism (<10%)3. Can be staged procedure or revisional procedure

for pts who failed a restrictive procedure (i.e. band or sleeve)

4. Most effective in diabetes improvements 97% remission for patients On insulin 5-10 yrs =88% remission On Insulin > 10 years = 66% remission

5. Causes favorable changes in gut hormones affecting long-term hunger and satiety (ghrelin)

6. Pyloric preservation procedure – minimizes likelihood of diarrhea

7. Euglycemia without causing hyperinsulinemia Insulin resistance reduction at muscle level

BariatricBariatric ProceduresProcedures Laparoscopic Duodenal Switch Procedure Risk

• Highest surgical risk• Longer OR time (2 ½ hours) • Longer hospital stay (3 days) • Protein/calorie malnutrition with poor

compliance • Greater malabsorption of vitamins/minerals

– Nutritional complications <5%• Highest risk for diarrhea with poor

compliance • Foul smelling stools/gas/diarrhea

– Esp with ↑ CHO and/or fat• Risk of excessive weight loss

Procedure ComparisonGastric Bypass Sleeve

GastrectomyDuodenal Switch

% EWL 59-94% 46-81% >80%

Bleeding 1.5-5% 0-3.6% 0.5-2%

Leak 0-1.9% 0-2.3% 1-3%

VTE 0.2-0.7% 0.2-3.39% 1-3%

Obstruction 0-3.4% 0-1.3% 1-2%

Death 0.4% 0.2% 1.2%

30 Day Outcomes30 Day OutcomesFY 2016 FinalProcedure Cases Readmit Reop ED visit SSI

RYGB 166 7 (4.2%) 6 (3.6%) 14 (8.4%) 8 (4.8%)

LVSG 94 5 (5.3%) 1 (1.1%) 5 (5.3%) 1 (1.1%)

Revision 66 4 (6%) 6 (9%) 3 (4.5%) 1 (1.5%)

Total 326 16 (4.9%) 13 (3.9%) 22 (6.7%) 10 (3%)

FY 2016 Surgical Complications

Gastric Bypass Sleeve Gastrectomy

Long term Surgical Outcomes












Why would you want to enter our program?

Comprehensive Certified Safety Extensive nutrition education Extensive medical evaluation Long term surveillance Support groups Hospital based/Springfield Clinic and SIU staffed

Endoscopic Bariatric Therapies

Curr Gastroenterology Rep (2016) 18:26

Intragastric BalloonORBERA RESHAPE DUO

IGBMECHANISMS OF ACTION Indications

I. DELAY GASTRIC EMPTYING

II. GASTRIC VOLUME REDUCTION

III. BARORECEPTOR STIMULATION- “STRETCH” RECEPTORS THAT AFFECT SATIETY AND HUNGER CONTROL BY ALTERING GUT HORMONES

1) PREEMPTIVE THERAPY BMI>30 AT RISK OF DISEASE DEVELOPMENT

2) METABOLIC THERAPY BMI>30 WITH COMORBIDITIES

3) PRIMARY THERAPY BMI> 30-40 (WEIGHT LOSS)

4) PREPARATION FOR SURGERY BMI >40 WHO ARE HIGH RISK

Balloon ProcedureIntragastric Balloon Best

• Ages 18-65• BMI- 30-40 KG/M2

–PREEMPTIVE,METABOLIC,PRIMARY

THERAPY)• SUPER OBESE BMI >50 IN

– PREPARATION TO BARIATRIC SURGERY

• HIGHER RISK BMI>40 PATIENTS– AWAITING TO HAVE SURGERY

• No previous stomach or GI surgery• MDT approach• High risk patients 20 high BMI (>40)

– for surgery optimization

Balloon ProcedureIntragastric Balloon Benefits

• Outpatient endoscopy with sedation

• No incision• No scar• Easy to perform• Faster recovery• Safe• Affordable?

Balloon ProcedureIntragastric Balloon Risk

• Device related GI side effects– Nausea/Vomiting/Abd Pain– GERD– Rare: obstruction, perforation,

aspiration pneumonia, death– Device intolerance 5%– Durability?

Balloon Outcomes1) Weight loss 17.8 kg in the range of (4.9 kg-28.5 kg)

2) %TWL -10-15 (1 year)

3) %EWL- 25 (1 year)

4) BMI REDUCTION- 4-9 KG/M2 (1 year)

5) SIGNIFICANT IMPROVEMENT OF COMORBIDITIES AND QOL

6) MUST BE USED WITH A MDT APPROACH TO ACHIEVE MAXIMUM BENEFIT

7) IT IS SAFE AND EFFECTIVE IN PRODUCING A SHORT TERM WEIGHT LOSS IN ABOUT ⅔ OF PATIENTS

8) DATA IS LACKING ON SUCCESS OF WEIGHT MAINTENANCE AND EVOLUTION OF COMORBIDITIES BEYOND 2 YEARS

The Pre-Operative Evaluation Phase is essential for selecting appropriate patients to ensure safe and quality outcomes

Health & Medicine

Don’t Give up on Your New Year’s Resolution