Bariatric surgery–from morbid obesity to obese morbidity

Dr Alexander Miras

MRC Clinical Research Fellow

Imperial Weight Centre - Charing Cross Hospital

Metabolic Imaging Group - Hammersmith Hospital

What’s happening in the UK?

• No money!

• Some authorities have stopped bariatric surgery

• Others follow the NICE guidelines (BMI>35 or

40)

• Others operate only on patients with BMI>50

London underground newspaper

North West London

• We operate on patients with BMI>35 and:

• Sleep apnoea/hypopnoea

• Uncontrolled hypertension/stable CVD

• Type 2 Diabetes Mellitus

• Infertility

Case 1

• 43 year old lady

• BMI 45

• No cardiovascular/respiratory disease

• No evidence of Type 2 Diabetes

• 2 children, peri menopausal

• University lecturer

• Plays tennis twice a week

• On Thyroxine 100mcg od

Case 2

• 43 year old lady

• BMI 45

• No cardiovascular/respiratory disease

• Impaired fasting glycaemia

• Fasting glucose 6.8 mmol/l (122.4 mg/dl)

• Fasting Insulin 20 mu/l

• 2 children, regular periods

• University lecturer

• Plays tennis twice a week

• On Thyroxine 100mcg od

Case 3

• 43 year old lady

• BMI 45

• No cardiovascular/respiratory disease

• No evidence of Type 2 Diabetes

• 2 children, regular periods

• University lecturer-just quit

• Mobilises with crutches, severe knee OA

• Needs 3rd party assistance for daily life

• “My quality of life is very poor”

• On Thyroxine 100mcg od and painkillers

Case 4

• 43 year old lady

• BMI 45

• Home oxygen-cor pulmonale

• Exercise tolerance 10 meters

• Type 2 Diabetes with microvascular complications

• 2 children, regular periods

• Unemployed

• House bound

• Polypharmacy

Case 5

• 55 year old gentleman

• BMI 60

• Sleep apnoea on CPAP

• 2 cardiac stents, BP 149/96

• Type 2 Diabetes for 5 years

• HbA1c 10.6% (92.3 mmol/mol)

• Total cholesterol/HDL ratio 9.2

• University lecturer

• Walks twice a week

• On 4 agents for T2DM, Antiplatelets, statin, 4

antihypertensives, Thyroxine 100mcg od

Historical Classifications - Sharma AM , Int J Obes 2009

“Morbid Obesity” – Scott and Law 1970

Recent Classifications

• Before 1985: Metropolitan Life Insurance

Company height-weight tables

• 1985: NIH Consensus Conference

recommended the use of BMI

• 1997: WHO adopts BMI

• Waist Circumference and Waist-to-Hip ratio also

recommended

WHO classification

2.5

2.0

1.5

1.0

0 20 25 30 35 40

BMI

Mortality Ratio

Cardiovascular and Diabetes Mellitus

Moderate Very Low

Low Moderate High Very High

Reprinted from Gray. Med Clin North Am. 1989;73(1):1-13, based on statistical information from Lew et al.

J Chron Dis. 1979;32:563-576.

OBESITY AND MORTALITY RISK

Limitations

• Lack of sensitivity and specificity

• No incorporation of comorbidities

• No measure of functionality, QoL, risk

• Poor correlation with overall health

Weight Management vs Obese Morbidity

Clinic Treatment

kg Weight

management Stop

coming

Multi-

modal

Strategy

Morbid Obesity Obese Morbidity

9 domain

assessment

P1

P2

P3

Weight sensitive?

Weight resistant?

Non-weight related?

Therapy specific?

Morbidity and weight loss sensitivity or resistance

Metabolic

Ventilatory

Reproductive

CV risk

Perceived health status

ADL / QoL

Eating behaviour

Anxiety / depression

Body Image dysphoria

Economic cost

-5 -10 -15 -20 -25 -30

% weight

loss to

improve

morbidity

Aylwin 2005

Benefits of a good classification system

• Stratification of patients

• Treatment decision making

• Application of guidelines

• Audit/Research

Edmonton Obesity Staging System (EOSS)

Stage 0

Sharma AM & Kushner RF, Int J Obes 2009

Stage 1

Stage 2

Stage 3

Stage 4

co-morbidity

moderate

moderate

Obesity

Edmonton score

Sharma et al, IJO 2009

EOSS Predicts Mortality in NHANES III

Padwal R, Sharma AM et al. CMAJ 2011

EOSS Predicts Mortality at Every Level of BMI

Padwal R, Sharma AM et al. CMAJ 2011

Overweight

EOSS Distribution Across BMI Categories

NHANES III (1988-1994)

Overweight

Class

III

Padwal R, Sharma AM et al. CMAJ 2011

50 million

23 million

10 million

6 million

EOSS Case 1

24 year-old physically active female,

BMI of 32 Kg/m2

no demonstrable risk factors, no functional

limitations, or mental health issues

Class I, Stage 0 Obesity

- Focus on prevention of further weight gain

- Health benefits of more aggressive obesity

treatment likely marginal

Sharma AM & Kushner RF, Int J Obes 2009

EOSS Case 2

32 year-old male

BMI of 36 Kg/m2

hypertension, sleep apnea, depression

Class 2, Stage 2 Obesity

- Clear benefits of obesity treatment

Sharma AM & Kushner RF, Int J Obes 2009

EOSS Case 3

63 year-old male

BMI of 54 Kg/m2

disabling osteoarthritis (wheel chair)

severe hypoventilation, fibromyalgia, generalized

anxiety disorder

Class 3, Stage 4 Obesity

- Aggressive obesity treatment unless deemed

palliative

Sharma AM & Kushner RF, Int J Obes 2009

Good points

• Incorporates comorbidities, function, QoL,

psychology

• Does not use BMI

• Management suggestions (?)

Bad points

• Relies on constantly changing definitions

• Are the conditions obesity related or not?

• Subjective parameters

• Difficult to confidently allocate patients

• Difficult to capture success of treatment

Aims

• To study the utility of King’s Criteria in assessing obese patients

A. Patient health stage scores

144 obese patients assessed before bariatric surgery

(BMI48±7)

and again 1 year after surgery (BMI 37±7)

B. Observer consistency

11 clinicians scored the same 12 patients in the 9 health

domains

(based on written information)

Obesity Staging Score: Aylwin et al Front Horm Res 2008

Aasheim E et al, Clinical Obesity 2011

Methods

Basis for assigning King’s Criteria scores:

Medical history

Clinical examination

Test results

“New Patient Questionnaire”

Effects of surgery

Aasheim E et al, Clinical Obesity 2011

Intra-Class

Correlations

0.62

0.93

0.66

0.78

0.86

0.54

0.76

0.51

0.28

Observers’ consistency (%)

Airways

BMI

CVD

Diabetes

Economical

Functional

Gonadal

Health status

Image of self

Aasheim E et al, Clinical Obesity 2011

Results: summary

King’s Criteria

• Captured obesity-related disease and tracked health

improvements after weight loss.

• Reasonable consistency in scoring among clinicians

Clinically useful

• Identifies which patients may gain most from treatment

• Provides baseline for later comparison

• Adds structure to MDT communication

• Shifts focus from losing weight to improving health

Limitations of King’s Criteria

• Relies on constantly changing definitions, but can be

adapted

• Are the conditions obesity related or not?

• Subjective parameters

• Potential improvements

• Refine staging definitions and weigh them

• Add more domains:

Junction of the gastro-esophagus

Kidneys

Liver

SOS NEJM 2007

Bariatric Surgery and Long-term Cardiovascular Events

Bariatric Surgery and Long-term Cardiovascular Events

Survival Among High-Risk Patients After Bariatric Surgery

RCT – At last

Bariatric surgery won’t:

• make you thin

• make you happy

Bariatric surgery will:

• make you healthier

• make you more functional

Acknowledgements

• Imperial Weight Centre • Dr Carel le Roux • Mr Torsten Olbers • Dr Florian Seyfried • Dr Ling Ling Chua • Miss Sabrina Jackson

• Institute of Clinical Sciences

• Prof Jimmy Bell • Dr Tony Goldstone • Dr Samantha Scholtz • Dr Christina Prechtl • Dr Sarah Ali • Miss Giuliana Durighel

• King’s College London • Dr Simon Aylwin

Case 6

• 43 year old lady

• BMI 45

• No cardiovascular/respiratory disease

• No evidence of Type 2 Diabetes

• 2 children, regular periods, divorced

• University lecturer-just quit

• Severe depression, house bound, regular

psychiatric follow up

• On Thyroxine 100mcg od and antidepressants

Case 7

• 70 year old lady

• BMI 45

• No cardiovascular/respiratory disease

• No evidence of Type 2 Diabetes

• 2 children, peri menopausal

• Retired University lecturer

• Plays tennis twice a week

• On Thyroxine 100mcg od

Case 8

• 43 year old Asian lady

• BMI 33.9

• 2 cardiac stents, BP 149/96

• Type 2 Diabetes for 5 years

• HbA1c 10.6% (92.3 mmol/mol)

• Total cholesterol/HDL ratio 9.2

• 2 children, regular periods

• University lecturer

• Plays tennis twice a week

• On 4 agents for T2DM, Antiplatelets, statin, 4

antihypertensives, Thyroxine 100mcg od