Update on Bariatrics Nothing to Disclose Jonathan Carter, MD - - PowerPoint PPT Presentation

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Update on Bariatrics Nothing to Disclose Jonathan Carter, MD Jonathan Carter, MD Associate Professor of Surgery Associate Professor of Surgery 6/20/2018 6/20/2018 Case Presentation: Patty 33 year-old woman with morbid obesity. 55

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6/20/2018

Jonathan Carter, MD Associate Professor of Surgery

Update on Bariatrics

6/20/2018

Jonathan Carter, MD Associate Professor of Surgery

Nothing to Disclose

33 year-old woman with morbid obesity. 5’5” 262 lbs BMI 44 Morbidly obese since childhood. She has tried Weight Watchers, Curves, South Beach Diet, Low Carb Diet, Atkins Diet, Slim-Fast, Nutrisystem and the UCSF Medically Managed Weight Loss Program. Although she has been able to lose some weight from diets and exercise, over time the weight has always returned, and she has remained morbidly obese Past Medical History Hypertension Migraine Diabetes mellitus (HBA1C 6.7%) Asthma Intertrigo Urinary stress incontinence Polycystic ovarian syndrome

Case Presentation: Patty Patty 262 lbs

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1. There are more and more patients like Patty and the

besity epidemic continues without a plateau in sight.

2. We have new insights about why diets fail in the long run. 3. No effective and durable drug therapy for severe

besity exists.

4. Bariatric surgery has evolved rapidly

Band out, Sleeve in, Bypass still the gold standard
Safety now better than cholecystectomy,

hysterectomy.

Durability of weight loss now firmly established.
Metabolic surgery is now the focus.

What can we offer Patty?

1. There are more and more patients like Patty and the

besity epidemic continues without a plateau in sight.

2. We have new insights about why diets fail in the long run. 3. No effective and durable drug therapy for severe

besity exists.

4. Bariatric surgery has evolved rapidly

Band out, Sleeve in, Bypass still the gold standard
Safety now better than cholecystectomy,

hysterectomy.

Durability of weight loss now firmly established.
Metabolic surgery is now the focus.

What can we offer Patty?

1990

https://stateofobesity.org/adult-obesity/

1995

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2000 2003 2004 2005

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2006 2007 2008 2009

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2010 2011 2012 2013

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2014 2015 2016

Why is obesity unhealthy?

Mechanick et al. SOARD 2008 CARDIOVASCULAR Hypertension Congestive Heart Failure Cor pulmonale Varicose veins Pulmonary embolism Coronary artery disease ENDOCRINE Metabolic syndrome Type 2 diabetes Dyslipidemia Polycystic ovary syndrome Amenorrhea, infertility, menstrual disorders MUSCULOSKELETAL Gout Osteoarthritis Lower back pain Carpal tunnel syndrome SKIN dermatoliposclerosis lymphedema cellulitis intertrigo hidradenitis suppurativa RESPIRATORY

bstructive sleep apnea

Pickwickian syndrome asthma GASTROINTESTINAL GERD Fatty liver disease / NASH Hernia Colon cancer GENITOURINARY Urinary stress incontinence Obesity-related glomerulonephropathy Hypogonadism Breast and uterine cancer Pregnancy complications NEUROLOGIC Stroke Idiopathic intracranial hypertension Meralgia paresthetica Dementia PSYCHOLOGIC Depression Low self-esteem Body image disturbance Social stigmatization

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Obesity reduces life expectancy

Years of lost life expectancy in women

25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45

BODY MASS INDEX

10 8 6 4

1. There are more and more patients like Patty and the

besity epidemic continues without a plateau in sight.

2. We have new insights about why diets fail in the long run. 3. No effective and durable drug therapy for severe

besity exists.

4. Bariatric surgery has evolved rapidly

Band out, Sleeve in, Bypass still the gold standard
Safety now better than cholecystectomy,

hysterectomy.

Durability of weight loss now firmly established.
Metabolic surgery is now the focus.

What can we offer Patty?

Randomly assigned 811 patients to 4 groups: low fat, low protein high fat, high protein low fat, high protein high fat, low protein Intensive group/individual instructional sessions Intensive follow-up to 2 years

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Katan, NEJM 2009

“They [study patients] were offered 59 group and 13 individual training sessions over the course of two years… [But] even these highly motivated, intelligent participants, who were coached by expert professionals, could not achieve the weight losses needed to reverse the obesity epidemic.”

30 weeks: VLCD exercise 14 participants of “The Biggest Loser” competition Participants were studied

1. prior to participation in the show
2. at the end of the 30 week competition
3. 6 years later

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Indirect calorimetry to measure resting metabolic rate Fast for 12 hours Breathe into Outcome variables Methodology Measured resting metabolic rate (RMR)

Indirect calorimetry
Fast for 12 hours, then lay supine
Breath into metabolic cart for 15 min
Measure O2 intake and CO2 emission
Calculate Resting Metabolic Rate (RMR)

Body composition Predicted RMR

By dual-energy x-ray absorptiometry
Measures Fat Mass (FM) and Fat-Free Mass (FFM)

Total energy expenditure

Clearance of 18O H2O and 2H H2O over 2 weeks
CO2 generation calculated, used to calculate TEE

Metabolic Adaptation

= RMR (measured) – RMR (predicted) = the difference between what you are actually burning versus what you should be burning based upon your body composition, age, and sex. Reflects the body’s ability to slow metabolic rate in order to preserve fat mass In lay terms, is the body’s “starvation mode”

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What happened at 6 years?

Body weight change in kilograms Fat-free mass change in kilograms Fat mass change in kilograms

What happened at 6 years?

Metabolic adaptation foils long-term attempts at dieting Obesity is not a disease of gluttons and sloths. The body acts to preserve the fat mass set point. Diet and exercise do not change the set point.

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1. There are more and more patients like Patty and the

besity epidemic continues without a plateau in sight.

2. We have new insights about why diets fail in the long run. 3. No effective and durable drug therapy for obesity exists. 4. Bariatric surgery has evolved rapidly

Band out, Sleeve in, Bypass still the gold standard
Safety now better than chole or
The weight stays off for most – rigorous durability
Metabolic surgery more and more accepted

What can we offer Patty?