Obesity, Weight Loss and Metabolic SurgeryJim Hewes

UGI and Bariatric Surgeon

Head of service NBT

Aims

• Scale of the problem and costs

• Myths

• Mechanisms behind obesity

• Types of operation and mechanism of action

• Outcomes

• NICE guidance

• Case study

Scale of the problemBMI>25 BMI>30

Scale of the problem

• 34,000 deaths/year attributable to obesity

• 6.8% of all deaths in England

• 9000 premature (before retirement age)*

• Cost to UK economy of overweight and obesity

• £15.8 bn/yr 2007

• £4.2 bn NHS costs**

• T2DM

• 3.2m people (1:20) in UK

• 10% of NHS budget spent on T2DM

• 1:6 hospital beds, 135 amputations per week

• 24,000 preventable deaths per year

* HoC select committee, 2004 **Public Health England

Effects of obesity

Risk factors of obese people developing selected diseases

Risk factors of obese people developing selected diseases

Myths ?

• Obesity is down to poor lifestyle choices driven by will power

• ‘I am thin so why can’t they be’

• ‘No fat people in Ethiopia’

• Surgery expensive method of devolving responsibility for poor behaviour

• Surgery is dangerous and should only be used for extreme cases

• Most patients regret having the operation

• ‘Opens a psychological can of worms’

Prejudice: BBC website comments

‘I have a 21stone relative with a bad heart, and diabetes, who won't diet or exercise or even admit he has a problem. But as he has self induced diabetes he gets free prescriptions. I am 9 stone with rheumatoid arthritis and am penalised by having to pay prescription costs.

He needs therapy not a gastric band. I don't need to pay NI for his sort.’

Prejudice: BBC website comments

‘I have a 21stone relative with a bad heart, and diabetes, who won't diet or exercise or even admit he has a problem. But as he has self induced diabetes he gets free prescriptions. I am 9 stone with rheumatoid arthritis and am penalised by having to pay prescription costs.

He needs therapy not a gastric band. I don't need to pay NI for his sort.’

Prejudice: BBC website comments

‘I have a 21stone relative with a bad heart, and diabetes, who won't diet or exercise or even admit he has a problem. But as he has self induced diabetes he gets free prescriptions. I am 9 stone with rheumatoid arthritis and am penalised by having to pay prescription costs.

He needs therapy not a gastric band. I don't need to pay NI for his sort.’

Prejudice: BBC website comments

‘I have a 21stone relative with a bad heart, and diabetes, who won't diet or exercise or even admit he has a problem. But as he has self induced diabetes he gets free prescriptions. I am 9 stone with rheumatoid arthritis and am penalised by having to pay prescription costs.

He needs therapy not a gastric band. I don't need to pay NI for his sort.’

‘Why is the NHS squandering any of its scarce resources treating self-inflicted illnesses. Let the obese eat themselves to death.’

Prejudice: BBC website comments

‘I have a 21stone relative with a bad heart, and diabetes, who won't diet or exercise or even admit he has a problem. But as he has self induced diabetes he gets free prescriptions. I am 9 stone with rheumatoid arthritis and am penalised by having to pay prescription costs.

He needs therapy not a gastric band. I don't need to pay NI for his sort.’

‘Why is the NHS squandering any of its scarce resources treating self-inflicted illnesses. Let the obese eat themselves to death.’

‘Perfect Storm’ for obesity

• Environmental Changes (obesogenic)

• Altered food supply

• Decreased physical activity

• Stress and distress

• Drugs

• Re-regulate energy balance and increase set point

‘Perfect Storm’ for obesity

• Environmental Changes (obesogenic)

• Altered food supply

• Decreased physical activity

• Stress and distress

• Drugs

• Re-regulate energy balance and set point

Defense of a Set point

• Not ‘will power’

• Disordered energy regulation system

• SET POINT

• Diets don’t work (3-6kg 1 yr)

• Surgery only way to reduce set point

Bariatric Surgery: Adjustable Gastric Band

Roux-en-Y Gastric Bypass

Sleeve Gastrectomy

Mechanisms of action

• Physiological. Changes in:

• Gut hormones

• Neural Signalling

• Intestinal Flora

• Bile acid and lipid metabolism

• Mechanical

• Changes eating behaviours (dumping, taste changes)

Evidence for physiological mechanisms of surgery

• Dramatic effects on hunger and satiety

• Few patients become underweight

• Transient weight gain in pregnancy

• Little weight loss in thin patients

• Changes in endocrine markers

• Ghrelin, PYY, GLP-1, Amylin

• Increased energy expenditure

RYGB is the opposite of Restrictive Dieting

Diet RYGB

Energy Expenditure

Appetite

• Hunger

• Reward based eating

• Satiety

Stress Response

Gut Peptides

• Ghrelin

• GLP-1, PYY, CCK, Amylin

Surgery changes set point

Surgical Outcomes NBSR UK data 2014

• >18,000 patients in 3 years

• 9000 LPGB, 4000 LAGB, 4000 LSG

• In hospital mortality 0.07%

• Complication rate 3%

• Post op stay 2.7 day

• 99% laparoscopic operations

• SAFE and EFFECTIVE despite operating on heavier, older and sicker patients

Safety profile and healthcare usage. KCH (unpublished)

• 700 patients (100/group)

• BS younger

• Highest baseline risk

• No mortality in any group

• No 30d readmissions for BS/MS0

2

4

6

8

10

12

BS GB Hern CR

LOS (d)

BS/MS high safety profile with low healthcare usage

0

2

4

6

8

10

12

14

16

18

BS GB Hern CR

30d Com(%)

0

2

4

6

8

10

12

BS GB Hern CR

Reop (%)

Follow up data

• 1 year

• EWL 58%

• 36% LAGB, 68% LPGB, 58% LSG

• Pre-op functional impairment (64% to 28%)

• OSA 60% off treatment

• 2 years

• 65% of patients with T2DM on no meds

• 3 years

• 59% EWL

Follow up data

• 1 year

• EWL 58%

• 36% LAGB, 68% LPGB, 58% LSG

• Pre-op functional impairment (64% to 28%)

• OSA 60% off treatment

• 2 years

• 65% of patients with T2DM on no meds

• 3 years

• 59% EWL

Improvement of T2DM post surgery

Cost effectiveness of surgery

Cost effectiveness of diabetic surgery

• Savings from drugs alone surgery pays for itself in 2-3 years.

• Not including savings from complications of DM

• Reduction in benefit claims by 75% after 14 months

• £1.45bn increase to GDP due to increased productivity, reduction in health costs and benefits

Cost effectiveness of diabetic surgery

• Savings from drugs alone surgery pays for itself in 2-3 years.

• Not including savings from complications of DM

• Reduction in benefit claims by 75% after 14 months

• £1.45bn increase to GDP due to increased productivity, reduction in health costs and benefits

• Surgery gives better BG control than drugs

• Tariff 2016-

• LPGB: £6271

• LSG/LAGB: £4995

Recent articlesBMJ May 2016Diabetes Care

June 2016

NICE guidelines – update 2014

• BMI >40 or 35-40 with comorbidities

• All non surgical measures tried. Fit for surgery

• Intensive Tier 3 input

• Commitment to long term FU

• Surgery first choice if BMI >50

• BMI >35 recent onset T2DM expedite surgery

• BMI 30-35 with recent onset T2DM consider surgery

• Asian origin consider surgery at lower BMI points

What we offer

Surgery

Non surgical

management

Population wide services

Lifestyle Interventions

Tier 4

NHSE CCG

Tier 3

CCG

Tier 2

Tier 1

Case study

• 48yr male. 186kg, BMI 49

• T2DM (5 yrs)

• HTN, Dyslipidaemia

• OSA on CPAP

• BKA and recurrent cellulitis (RTA)

• Amlodipine, aspirin, furosemide, ramipril, simvastatin, pioglitazone, lantus/novorapid (350u/day, £3k/yr)

• Weight problematic all life. Tried all diets. Yo-yo. Miserable

• Full T3 and T4 assessment

• Lap Gastric Bypass. Discharged D2 well

Weight Loss

80

100

120

140

160

180

200

No

v-1

1

Jan

-12

Mar

-12

May

-12

Jul-

12

Sep

-12

No

v-1

2

Jan

-13

Mar

-13

May

-13

Jul-

13

Sep

-13

No

v-1

3

Jan

-14

Mar

-14

May

-14

Jul-

14

Sep

-14

No

v-1

4

Jan

-15

Mar

-15

May

-15

Jul-

15

Sep

-15

No

v-1

5

Jan

-16

Mar

-16

BYPASS

TIER 3

TIER 4

Post op

• Weight loss 74kg since presentation (BMI 30)

• HbA1C – 37mmol/mol off all diabetic medication (stopped insulin on day of surgery)

• Off CPAP

• On Vitamin and mineral supplementation as per guidelines

• Minimal loose skin, exercising regularly

• ‘Feels like a new man’

• Care transferred back to primary care after 2 yrs

Summary

• Obesity is significant worldwide problem

• Multifactorial aetiology

• Energy balance and set point complex

• Bariatric/Metabolic surgery is

• Safe and effective (clinically and financially)

• Only therapy that has proven long term benefit

• Shift from treating weight to disease

• DM, IIH, OSA, GORD, Infertility, Menorrhagia

• What should we be spending NHS money on?

Any Questions?