Bariatric Surgery: A Cost-effective

Treatment of Obesity?

Shaneeta M. Johnson MD FACS FASMBS2018 NMA Professional Development Seminar

Congressional Black Caucus FoundationAnnual Legislative Conference

Washington, DC

Greater than one-third of U.S. adults are obese

Estimated that one third of all children, one half of all black and Hispanic children born in 2000 will develop diabetes

Linked to type 2 diabetes, heart disease, hypertension, certain types of cancer and more

OBESITY

Prevalence of Childhood and Adult Obesity in the United States, 2011-2012 Cynthia L. Ogden, PhD1; Margaret D. Carroll, MSPH1; Brian K. Kit, MD, MPH1,2; Katherine M. Flegal, PhD JAMA. 2014;311(8):806-814. doi:10.1001/jama.2014.732.

The Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report

Obesity costs

Estimated annual cost of $147 billion in 2008

$1,500 higher medical costs than those of normal weight

Decreased productivity due to ‘absenteeism’

Presenteeism - decreased productivity

Preventive, diagnostic, and treatment services related to obesity

Eric A. Finkelstein, Justin G. Trogdon, Joel W. Cohen and William Dietz Annual Medical Spending Attributable To Obesity: Payer-And Service-Specific Estimates Health Affairs 28, no.5 (2009):w822-w831

Obesity as a Disease

American Medical Association - recognized obesity “as a disease state with multiple pathophysiological aspects

requiring a range of interventions to advance obesity treatment and prevention”

June 2013

Bariatric Surgery

“[Bariatric surgery] is the most effective treatment to date, resulting in sustainable and significant weight loss along with resolution of weight-related health conditions in up to 80% [of people].

ASMBS/ASGE white paper, 2011

Recommended by the American Diabetes Association (ADA) as a treatment for diabetes

Bariatric SurgeryEndorsements

Prevalence¶ of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2016

¶ 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 Obesity

Prevalence of Self-Reported Obesity Among Non-Hispanic Black Adults, by State and Territory, BRFSS, 2014-2016

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

Prevalence of Obesity in African-Americans

IncreasedMedical Costs

Obesity

PrematureDeath

Comorbid Diseases

Disability

Reduced Quality of Life

The Impact of Obesity

Obesity-related Disease

The Harmful Effects of Obesity

Liver disease

Gallbladderdisease

OsteoarthritisGout

Asthma

Heart disease

Menstrual/Infertility problems

Type 2 diabetes

High blood pressure

Sleep apnea

GERD

Migraines

Urinary Incontinence

Venous diseaseand leg swelling

•Increased chance of developing one of these

and/or additional diseases:

Risks of Obesity

BMI 30-35=

Reduced Median survivalby 2-4 years

Body mass index (BMI)=

Strong predictor ofoverall mortality

BMI > 30 associated with

Risk of Premature death

Office of the Surgeon General – US Department of Health and Human Services. Overweight and Obesity: health consequencesKaplan, L.M. (2003) Body weight regulation and obesity. Journal of Gastrointetinal Surgery. 7(4) pp. 443-51.

Risks of ObesityCancer Risks

Esophageal Cancer

Pancreatic Cancer

Colon and Rectal Cancer

Thyroid Cancer

Breast Cancer

Endometrial Cancer

Kidney Cancer

Women: 50,500Men: 34,000

500,000 new US cases by 2030

(estimate)

Obesity and Cancer Risk – National Cancer Institute

Minimally Invasive Bariatric Surgery

• Surgery altering the gastrointestinal tract to cause weight loss• Effective means of losing substantial weight and maintaining that

weight loss• Affects the numerous comorbidities associated with obesity• Considered Metabolic Surgery• Indicated for severely obese patients

Who is a Surgical Candidate?

• 100 lbs over ideal body weight

• OR BMI equal to or > 40

• OR BMI equal to or > 35 complicated by other medical conditions

• eg. diabetes, high blood pressure

Category BMI % Over IBWUnderweight < 18.5

Normal 18.5 –24.9

Overweight 25.0 –29.9

Obesity (Class 1)

30 – 34.9 > 20%

Severe Obesity (Class 2)

35 – 39.9 > 100%

(Class 3)40 – 49.9

Super obesity > 50 > 250%

Bariatric SurgeryThe numbers

2011 2012 2013 2014 2015 2016 2017

Total 158,000 173,000 179,000 193,000 196,000 216,000 228,000

Sleeve 17.80% 33.00% 42.10% 51.70% 53.61% 58.11% 59.39%

RYGB 36.70% 37.50% 34.20% 26.80% 23.02% 18.69% 17.80%

Band 35.40% 20.20% 14.00% 9.50% 5.68% 3.39% 2.77%

BPD-DS 0.90% 1.00% 1.00% 0.40% 0.60% 0.57% 0.70%

Revision 6.00% 6.00% 6.00% 11.50% 13.55% 13.95% 14.14%

Other 3.20% 2.30% 2.70% 0.10% 3.19% 2.63% 2.46%

Balloons — — — — 0.36% 2.66% 2.75%

Estimate of Bariatric Surgery Numbers, 2011-2017

Published June 2018The ASMBS total bariatric procedure numbers are based on the best estimation from available data (BOLD,ACS/MBSAQIP, National Inpatient Sample Data and outpatient estimations).

Primary Metabolic and Bariatric ProceduresLaparoscopic Gastric Bypass

• Stomach reduced to size of walnut, attached to jejunum, thereby bypassing a portion of small intestine

• Limits consumption and absorption of calories

• Risks: Allergic reactions, pulmonary emboli, deep vein thrombosis, infection, cardiovascular or pulmonary risks, nutritional deficiencies

Primary Metabolic and Bariatric ProceduresSleeve Gastrectomy

• Stomach divided and stapled vertically, removing a portion stomach, creating banana-shaped pouch

• Restricts amount of food and consumed and absorbed

• Risks: GERD, infection, gastritis, pulmonary emboli, nutritional deficiencies

Bariatric Surgery It’s SAFE!

Increased minimally invasive surgery

Advanced surgical techniques

American College of Surgeons (ACS) and American Society of Metabolic and Bariatric Surgeons (ASMBS) accreditation program

Bariatric SurgeryLow Mortality Rate

0.00%

0.10%

0.20%

0.30%

0.40%

0.50%

0.60%

0.70%

0.80%

0.90%

1.00%

Mortality Rate

Mortality Rate

Bariatric Surgery Gallbladder Removal Hip Replacement Surgery

Bariatric Surgery

Gallbladderremoval

Hip replacementsurgery

Agency for Healthcare Research and Quality (AHRQ (2007), Statistical Brief #23. Bariatric Surgery Utilization and Outcomes in 1998 and 2004.

Bariatric Surgery

BMI >30

50% increased risk of premature

death

Bariatric surgery increases lifespan

Gastric bypassreduce risk

of premature death by 40%

Increase life expectancy

by 89%

Risks of morbid obesityoutweigh risks

of surgery

U.S. Department of Health and Human Services Office of the Surgeon General. (2007). Overweight and obesity: health consequencesEffects of bariatric surgery on mortality in Swedish obese subjects. New England Journal of Medicine. 357 pp741-752

Adams, T. D. et al. (2007) Long-term mortality after gastric bypass surgery. New England Journal of Medicine 357pp.753-761

Bariatric SurgeryIt’s Effective!

60%excess weightat 6 months

77%excess weightat 12 months

50%excess weight

at 5 years

Wittgrove, A.C., et al. (2000). Laparosocpic gastric bypass, roux-en-y: 500 patients: technique and results, with 3-60 month follow-up. Obesity Surgery. 10(3) pp.223-239

Bariatric SurgeryImpact on Mortality

Improve or resolve more than 40

obesity-related diseases and

conditions

% Reduction in mortality Disease/Condition

60% reductionCancer

esp. breast and colon cancer

56% reduction Coronary artery disease

92% reduction Type 2 diabetes

40% overall reduction

Overall reduction in gastric bypass

patients

Adams, T.D. et al. (2007). Long-term mortality after gastric bypass surgery. New England Journal of Medicine. 357 pp.753-761Christou, N.V., et al. (2008). Bariatric Surgery reduces cancer risk in morbidly obese patients. Surgery for Obesity and Related Diseases. 4(6) pp. 691-95

Bariatric SurgeryMedical Outcomes

Condition/Disease % Resolved or Improved % Resolved

Type 2 Diabetes 86% 76.8%

Hypertension 78.5% 61.7%

Obstructive Sleep Apnea 85.7% 83.6%

Hyperlipidemia 78.5% 61.7%

Buchwald, H, et al. (2004). Bariatric surgery: a systematic review and meta-analysis. Journal of the American Medical Association 292(12) pp.1724-1737

Health Benefits of Weight Lossafter Bariatric Surgery

• ↑Quality of Life

• ↑ Life expectancy

• Diabetes resolved/improved

• High blood pressure resolved/improved

• Improved/resolved depression

• Decreased heart risks

Bariatric Surgery

33,718 patients,13 comorbidities with

at least 1% prevalencebefore surgery

Diabetes

Hypertension

Economics of Bariatric SurgeryHealth care

costs

29% in 5 years

Payers recover bariatric

surgery costs within

2-4 years

Worker productivity

$2,765/year for employers

Costs =$11,500 - $26,000

Sampalis J.S., et al. (2004). Impact of weight reduction surgery on health care costs in morbidly obese patients. Obesity Surgery. 14(7) pp. 939-47Cremieux et al (2008) A study of economic impact of bariatric surgery. The American Journal of Managed Care. 14(9) pp 589-596

Bariatric Surgeryin African-Americans

• Obesity is highest among African-American populations

• Obese African-American patients have a higher prevalence of obesity-related comorbidities

• Most patients undergoing bariatric surgery are Caucasian

Bariatric surgery outcomes in black patients with super morbid obesity

Significant decrease in weight and BMI

Significant improvement or resolution of hypertension, type 2 diabetes and

hyperlipidemia

Onyewu, Fullum et. Al Bariatric surgery outcomes in black patients with super morbid obesity: a 1-year postoperative review

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Preoperative Weight Postoperative Weight

Weight (lbs)

Weight (lbs)

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Preoperative BMI Postoperative BMI

BMI kg/m2

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STAMPEDE Trial

150 patients underwent either intense medical

therapy,

or

gastric bypass or sleeve

gastrectomy

STAMPEDE TRIAL

HgbA1c of <6.0 at five years

Surgery- 29%Medical – 5%

Weight loss

Surgery -23%Medical – 5%

88% of insulin at 5 years

in surgical arm

Decreased diabetic and cardiac meds

Surgery-35%Medical-13%

Morehouse School of Medicine

• Comprehensive Bariatric Surgery Program

– Nutritional counseling

– Psychological counseling

– Partnerships with Sleep medicine, Endocrinology, Cardiology, Pulmonary, and more

• Optimal Wellness Program

– Stress medicine

– Exercise physiology

– Nutritional counseling

Bariatric Surgery• Effective means for resolution of obesity• Significant effect on obesity-related diseases• Effective treatment for African-Americans with obesity and

comorbidities• Most effective as part of a comprehensive obesity

approach