Transcript Surgical Treatment of Obesity

‫چاقی و درمان‬
‫دکتر اکرم نوری‬
4
Obesity and Life Expectancy
• If current rates of
obesity are left
unchecked, the current
generation of American
children will be the first
in two centuries to have
a shorter life expectancy
than their parents.
Olshansky SJ, et al. A Potential Decline in Life Expectancy
in the United States in the 21st Century. NEJM, 352(11):11381145, 2005
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Contributors to weight gain
•
•
•
•
•
•
Socio-economic status
Smoking cessation
Hormonal
Inactivity
Psychosocial/emotions
Medications
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‫برای ارزیابی چاقی از ‪ BMI‬استفاده‬
‫میکنیم‬
‫‪BMI = wt/ht²‬‬
‫)‪(kg/m²‬‬
Definition
• A BMI of 25.0 to 29.9 kg per m2 is
defined as overweight; a BMI of
30.0 kg per m2 or more is defined
as obesity.
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‫‪The Risks of Overweight‬‬
‫بیماری عروق کرونر‪/‬نارسایی قلبی‬
‫سرطان پستان ‪/‬پروستات ‪/‬کولون ‪ /‬رحم ‪/‬کبد ‪/‬کلیه ‪/‬پانکراس ‪/‬مری‬
‫سکته مغزی‬
‫آرتروز‪/‬نقرس‬
‫بیماری کیسه صفرا‬
‫یبوست ‪ /‬عقیمی در زنان‬
‫آسم ‪/‬دیگر مشکالت تنفسی ‪sleep apnea,‬‬
‫هیپرتانسیون ‪/‬دیابت ملیتوس ‪/‬کلسترول باال‬
‫بهترین روش درمان چاقی عبارتند از‪........‬‬
Weight Loss Strategies
•
•
•
•
•
•
Diet therapy
Increased Physical Activity
Pharmacotherapy
Behavioral Therapy
Surgery
Any combination of the above
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Get patients to look like models?

NOT ◦
Get patients to their ideal body weight?

NOT practical usually ◦
Get patients to lose 5-10% of body weight?

HOPEFULLY ◦
Get patients to exercise and reduce their
mortality risk?
DEFINITELY! ◦

A multibillion dollar commercial industry
Tow forms of modification :
1- diet
2- exercise
Dietary modification is an effective means of
inducing weight loss.
Physical activity-anything that raises
breathing and heart rates (brisk walking,
bicycling, dancing).Work up to one
hour/day.
Nutrition- increase fruits and vegetables,
and 1% milk. Decrease sugar drinks and
high saturated and trans fat foods (fast food
…)
Low Calorie Diet Treatment
􀂄 National Institutes of Health (NIH) Guidelines1:
􀂄 Overweight (BMI of 25.0 to 29.9 kg/m2 ) and two
cardiovascular disease risk factors
􀂄 decrease their energy intake by approximately 500
kcal/day
􀂄 Class I obesity (BMI of 30 to 34.9 kg/m2 )
􀂄 decrease their energy intake by approximately 500
kcal/day
􀂄 Class II or higher (BMI of 35.0 kg/m2 or higher
􀂄 energy deficit of 500 to 1000 kcal/day
􀂄 Composite results of trials indicate that an LCD
providing 1000 to 1500 kcal/day induces about an 8%
weight loss after 16 to 26 weeks of treatment.
Low calorie diet
(LCD)
Aims for an energy deficit ranging from 500
to 1000 kcal/day
LCD is a low fat
diet
LCD Helps losing 0.5
kg/week
That lead to a 10% weight loss over 6
months
Very low calorie diet
(VLCD)
VLCD is high protein diet with less fat &no
carbohydrate
Limits energy intake to fewer than
800kcal/day
VLCD helps losing 1-1.5
kg/week
Short term weight loss with VLCD is
dramatic with some people losing up to
20kg in 3 months.
But long term doesn’t differ from
LCD
VLCD require physician
supervision
􀂄 VLCDs induced a weight loss of about 15%
to 20% in
12 to 16 weeks of treatment, but this weight
loss was
not usually maintained
􀂄 In fact, several randomized trials have 
shown that
weight regain is greater after VLCD than LCD
therapy. 



􀂄 Side effects of these severe calorie restricted
diets
include: 
Orthostatic hypotension 􀂄 
Fatigue 􀂄 
Cold intolerance 􀂄 
Dry skin 􀂄 
Hair loss 􀂄 
Menstrual irregularities 􀂄 
Cholelithiasis 􀂄 
Cholecystitis 􀂄 
Pancreatitis (rare) 􀂄 

9 
:
􀂄 Several short term studies suggest that, despite equal energy intakes, initial weight loss

during the first 4 weeks
may be greater with a low-carbohydrate than with a high-carbohydrate diets.1 
􀂄 Possible xplanations for promotion of weight loss by low-carbohydrate diets, despite

unlimited fat and protein
Decreased insulin resistance 
Hypothesized delterious effects:2 􀂄 
Dehydration 􀂄 
Electrolyte imbalance 􀂄 
Hyperuricemia 􀂄 
Calciuria 􀂄 
Kidney stones 􀂄 
􀂄 Glycogen depletion with easy fatigue 
Hyperlipidemia 􀂄 
􀂄 No serious adverse effects were reported3 
􀂄 In fact, these diet changes have shown 43% decrease in plasma triglycerides, an 18% increase
in plasma HDLcholesterol,
and a 7% decrease in plasma LDL-cholesterol. Increased Hunger 

Recent Comparison Data of Low
Carbohydrate Diet to Low Fat
􀂄 Recent studies show that the low
carbohydrate
diets may be superior to low fat diets.1,2




Principles Of Dieting
• Women should consume atleast 1200 kcal/day,
men 1500 kcal/day.
• Select a diet that has:
>75g/day proteins (15% of total calories)
> 55% total calories from carbs
▪ Fat should contribute 30% or less of total calories
Atleast 3 meals/day.
High fiber (20-30g/day), fruits and vegetables.
Supplement the diet with multivitamis and minerals.
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High protein: Metabolic
Effects
Ketosis
dehydration, constipation and kidney stones
fatigue
??? alter cognitive functioning
High Saturated Fat
Increases in LDL-C and TC
Low Fruits, Vegetables and Grains
Deficient in micronutrients (Vitamin B, calcium, K)
and phytochemicals
Increases in serum uric acid
Denke M. Am J Cardiology 88(1):59-61, 2001.
St.Jeor ST, et al. Circulation 104:1869-1874,
2001.
Westman EC. Et al. Am J Med. 113(1): 30-6, 2002.
Other possible effects
Kidney stones
Osteoporosis
Chronic renal insufficiency
American Heart Association
Guidelines for Healthy Diets
Protein: 15-20% of calories
not excessive (50-100g/d)
proportional to carbohydrate and fat
Carbohydrates: ~55% of calories
of 100g/d
Minimum
Fat: ~30% of calories, <10% sat fat
Protein foods should not contribute
excess total fat, sat fat or cholesterol
Diet should provide adequate nutrients
and support dietary compliance
St. Jeor ST, etal. Circulation 104:1869-74,
2001.
Low Calorie Diets
Reduce total body weight by
average of 8% over 3-12 months
Greater initial loss with VLCD
No difference between VLCD and
LCD over long term (> 1 year)
NHLBI. Clinical guidelines on the identification, evaluation
and treatment of overweight and obesity in adults. 1998.
Dieting
• Dieting is highly
ineffective - 95%
long term failure
rate
• Often results in
higher weight than
before the diet
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Maintenance
After losing 10% of their weight or
more with 6 months of treatment,
patients typically regain approximately
one half of that weight within 1 year
and return to their baseline weight
within 5 years if they receive no further
treatment
Commercial Programs
Weight Watchers
• Traditional program includes a balanced low calorie diet
containing 1200 calories per day for women; 1800 calories
for men.
• Group meetings lead by successful program graduates
which provide support and advice on behavior modification,
exercise, and nutrition.
• Multivitamins
• 􀂄 Generally recommended in weight
loss.
• 􀂄 Data establishing effect on weight
loss is lacking.
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Behavior Therapy
• 􀂄 Second, eating and physical activity patterns are
learned
• behaviors and can be modified.
• 􀂄Behavior Modification Techniques
• 􀂄Self Monitoring
• 􀂄Stimulus Control
• 􀂄Behavioral Contracting
• 􀂄Cognitive Restructuring
• 􀂄Stress Management
• 􀂄Relapse Prevention
• 􀂄Social Support
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exersise
*
How good is exercise alone
for weight loss?
Not very effective
11 studies
5 found no change in weight w/ Exercise alone
6 showed slight weight loss w/ Exercise alone
1-2 kg
Facts on exercise in obesity
tx.



Exercise alone only leads to slight wt loss, if
any, but marked reduction in mortality
Adding moderate/vigorous aerobic exercise
to dieting slightly increases wt loss
Any type of exercise helps maintain wt loss,
but duration must be 4-10 hours/week
“The effects of 18 months of intermittent vs. continuous
exercise on aerobic capacity, body weight and
composition,in, moderately obese females.”

Two exercise groups:
 continuous
(30 min, 3d/wk, 60-75% VO2max)
 intermittent (brisk walking 15 min 2x/day, 5d/wk).

Weight loss:
 continuous
group: -2.1%
 intermittent group: none
exercise is very effective in preventing long
term weight regain.
At least ,doing exercise 3 times /week for
45 minute
Or doing 20 minute exercise each day
Obesity Drugs
Appetite suppressants
Noradrenergic (Schedule IV)
Phentermine (Adipex, Fastin)
Diethylpropion (Tenuate)
Noradrenergic (Schedule III)
Benzphetamine (Didrex)
Phendimetrazine (Bontril)
Serotonergic
Fenfluramine, dexfenfluramine
Mixed Noradrenergic & Serotonergic
Sibutramine (Meridia)
Nutrient absorption reducers
Lipase inhibitor
Orlistat (Xenical)
2. Increased exercise
• Exercise regularly
– Need to gradually work up to this
– Start with brisk walking 10-45 min, 3-5
days/week
– Work up to 60-80 min, most or all days/week
– Aim to expend 1,000 - 2,000 kcal/week
NHLBI, ACSM
Pharmacotherapy
NHLBI:
“FDA-approved pharmacotherapy can
be helpful adjunct for treatment of
obesity in some patients.”
Consider if lifestyle changes do not
promote weight loss after 6 months
Net average loss attributable to drugs 2
to 10 kg usually within first 6 months
NHLBI. Identification, evaluation and treatment of
overweight and obesity in adults. October 2000.
Sibutramine (Meridia)
Summary of Research Findings
 6% to 8% weight loss with 10 to 15 mg/day.
 2% weight loss with placebo.
 Published data available up to one year.
© 2000 University of Pennsylvania School of Medicine
NHLBI:



Limit drugs to BMI > 30 or BMI >27
w/concomitant risk factors or disease
Discontinue if patient does not lose 2 kg
in first 4 weeks
F/U visits include weight & BP check,
pulse, lab tests, discuss side effects and
answer questions
 2 - 4 weeks
 Monthly for 3 months
 q 3 months for 1st year
NHLBI. Identification, evaluation and treatment of
overweight and obesity in adults. October 2000.
Haddock CK et al. Intl J of Obesity. 26:252-273, 2002.
Sibutramine (Meridia)
Contraindicated: CAD, CHF, cardiac
arrhythmias or stroke
Side Effects: hypertension,
arrhythmia, tachycardia
pulse and BP should be checked
before treatment and every 2
weeks in the 1st 3 months and
every 1-3 months thereafter
Fernstrom MH. Postgraduate Med. June 2001,
10-18.
Bray GA. Nutrition. 16(10):953-60, 2000.
Carek PJ, Dickerson LM. Drugs. 57(6):883-904,
1999.
Wooltorton E. CMAJ. 166(10):1307-08, 2002.
Side Effects
Common
Headache
Dry mouth
Constipation
Insomnia
Stop treatment in patients who
experience:
an increase in heart rate of 10
beats/min
an increase in either SBP or DBP of
>10 mmHg in 2 consecutive visits
Sibutramine (Meridia)
Prescribing Information
 For patients with BMI > 30 or > 27 in the presence of
risk factors.
 5 to 15 mg per day.
 Not for patients on SSRIs (e.g. Paxil, Zoloft, Prozac)
 Not for patients with poorly controlled hypertension,
history of coronary artery disease, CHF, arrhythmia or
stroke.
 Regular BP and heart rate monitoring required.
© 2000 University of Pennsylvania School of Medicine
Orlistat
Lipase inhibitor that reduces fat
absorption by ~30% resulting in
reduction in energy intake
Inhibits digestion of dietary
triglycerides, decreases absorption
of cholesterol and lipid-soluble
vitamins
Fernstrom MH. Postgraduate Med. June 2001, 10-18.
Bray GA. Nutrition. 16(10):953-60, 2000.
Carek PJ, Dickerson LM. Drugs. 57(6):883-904, 1999.
Side Effects
GI side effects due to inhibition of
fat absorption
pain, fecal urgency, liquid stools,
flatulence with discharge, oily
spotting
Multivitamin recommended
because of reduction in absorption
of fat soluble vitamins (esp. A & E)
Summary: Meta-analysis
Placebo subtracted weight losses for
single drugs never exceeded 4.0 kg
No drug or class of drug exhibits clear
superiority
Increasing length of drug treatment
does not lead to more weight loss
Haddock CK, et al. Int J Obesity. 26:262-73, 2002.
Medications
A) Serotonin Nor-epinephrine Reuptake
Inhibitor: reduces food intake.
Sibutramine: initial dose 10mg/day, max
20mg/day.
B) Orlistat: Lipase inhibitor. Alters
metabolism, dec absorption of dietary fat.
120mg PO TID
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Surgery
2001 47,000
2002 63,000
2003 98,000
NIH Criteria:
Well informed and motivated patient
BMI>40 or
BMI>35 with co-morbidities
Mortality: 1-2%
Effectiveness: >50% excess weight loss at 14
years
Combine restrictive and malabsorptive
operation
Most common operative intervention in USA
Work by creation of a small proximal gastric
pouch with roux-en-y gastrojejunostomy
75% to 85% EBW within a couple years




Disadvantage of RNYGB
Anastomotic leak 20%
 Stricture 10%
 Nutritional disturbances
Especially, vitamine B12,iron &calcium
 cholelithiasis

Orlistat (Xenical):
Mechanism of Action
 Activity occurs in the stomach and small intestine.
 Inhibits gastric and pancreatic lipases.
 30% of ingested fat is unabsorbed and excreted.
 Minimal systemic absorption.
 Low-fat diet ( 30%) required to minimize side effects.
© 2000 University of Pennsylvania School of Medicine
Orlistat (Xenical)
Summary of Reported Adverse Events
Adverse Events
Overall Incidence
(% of Patients)
Oily spotting
26.6
Flatus with discharge
23.9
Fecal urgency
22.1
Oily stool
20.0
Oily evacuation
11.9
Increased defecation
10.8
Fecal incontinence
7.7
Package insert data, Orlistat, 1998.
© 2000 University of Pennsylvania School of Medicine
Orlistat (Xenical)
Prescribing Information
 120 mg TID with meals containing fat.
 Patients should be on a nutritionally balanced, low-fat
diet (< 30%) to minimize side effects.
 Prescribe multivitamin to be taken at least two hours
before or after the medication.
 Orlistat is contraindicated for pregnant or lactating
women, and those with chronic malabsorption
syndromes or cholestasis.
© 2000 University of Pennsylvania School of Medicine
Chronic Pharmacological
Treatment and Challenges
 Similar to pharmacotherapy of other chronic
conditions.
 Consistent weight gain seen when medications
are discontinued.
 Requires intensive risk/benefit analysis and
careful patient selection.
 Safe and effective medications.
© 2000 University of Pennsylvania School of Medicine
Surgery
• Roux-en-Y gastric bypass.
• Lap band procedure
Criteria: a) BMI > 40 or >35 with 2 comorbidities.
b) Failure of non surgical methods
c) Presence of 2 or more medical
conditions that would benefit with weight loss.
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Surgical Treatment of Obesity
 Patient selection criteria

BMI > 40 or > 35 for those with weight related co-morbidities.

History of failed conservative weight loss approaches.

No substance abuse and/or psychiatric disorders.
 Surgical options

Vertical banded gastroplasty (VBG)

Gastric bypass (GBP)
 Outcomes

Weight loss is 25% to 35% of initial weight.

Weight loss is generally well maintained.

Significant improvement in co-morbidities.
© 2000 University of Pennsylvania School of Medicine
Surgical Treatment of Obesity
Vertical Banded Gastroplasty (VBG)
Staple Line

Formation of small
proximal gastric pouch.

Restricts amount of food
without bypassing the gut.

Delays gastric emptying.

Creates feeling of early
satiety.
Pouch
Band
Fundus
© 2000 University of Pennsylvania School of Medicine
Surgical Treatment of Obesity
Gastric Bypass

Formation of 20-30 ml
proximal gastric pouch.

Delays gastric emptying.

Interferes with absorption
of nutrients.

May induce dumping
syndrome after high
carbohydrate meal.
Staple Line
Pouch
Fundus
Jejunum
© 2000 University of Pennsylvania School of Medicine
Surgical Treatment of Obesity
Vertical Banded Gastroplasty (VBG)
Staple Line

Formation of small
proximal gastric pouch.

Restricts amount of food
without bypassing the gut.

Delays gastric emptying.

Creates feeling of early
satiety.
Pouch
Band
Fundus
© 2000 University of Pennsylvania School of Medicine
BEST method of treatment
for obesity
is...
Treating obesity demands a multifaceted approach with chronic
monitoring
1.
2.
3.
4.
5.
Decreased caloric intake
Increased exercise
Behavioral modification
+/- Pharmacotherapy
+/- Surgery
Behavior modification
strategies, extended
treatment, and physical
activity are excellent
predictors of weight loss
during treatment.
Goals of treatment
• Get patients to look like models?
– NOT
• Get patients to their ideal body weight?
– NOT practical usually
• Get patients to lose 5-10% of body
weight?
– HOPEFULLY
• Get patients to exercise and reduce
their mortality risk?
– DEFINITELY!
Set reasonable
expectations
• Gradually develop regular exercise
• Gradually develop more healthy eating
• Shoot for losing 5-10% of body weight
first
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