Sponsored by

AAGLAdvancing Minimally Invasive Gynecology Worldwide

Obesity in Females: Why Is It Rising, What Are the Consequences to Female Healthcare,

and Are There Solutions?

PRESENTER

Mitchell S. Roslin, MD, FACS, FASMBS

Professional Education Information   Target Audience This educational activity is developed to meet the needs of residents, fellows and new minimally invasive specialists in the field of gynecology.  Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.  The AAGL designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.   DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As  a  provider  accredited  by  the Accreditation  Council  for  Continuing Medical  Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification  of  CME  needs,  determination  of  educational  objectives,  selection  and  presentation  of content,  selection  of  all  persons  and  organizations  that will  be  in  a  position  to  control  the  content, selection  of  educational methods,  and  evaluation  of  the  activity.  Course  chairs,  planning  committee members,  presenters,  authors, moderators,  panel members,  and  others  in  a  position  to  control  the content of this activity are required to disclose relevant financial relationships with commercial interests related  to  the subject matter of  this educational activity. Learners are able  to assess  the potential  for commercial  bias  in  information  when  complete  disclosure,  resolution  of  conflicts  of  interest,  and acknowledgment of  commercial  support are provided prior  to  the activity.  Informed  learners are  the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME.   

Table of Contents 

 Course Description ........................................................................................................................................ 1 

Disclosure ...................................................................................................................................................... 2 

Obesity In Females: Why is it rising, what are the consequences to female healthcare, and are there solutions? M.S. Roslin ..................................................................................................................................................... 3  Cultural and Linguistics Competency  ......................................................................................................... 12 

Lunchtime Symposium: 

Obesity in Females: Why Is It Rising, What Are the Consequences to  

Female Healthcare, and Are There Solutions? 

 Sponsored by Medtronic 

 Mitchell S. Roslin, Chair 

 Obesity continues to rise at alarming rights.   While there has been some stabilization  in males, recent studies have shown that 40% of adult females are obese, and a rising number are considered to have morbid  obesity.  Excess  fat  has  profound  implications  for  overall  health.  Reproductive  function  and outcomes  are  changed.  PCOS  is  rising  and  rates  of  infertility  higher  in  obese  females.  Obesity  is surpassing cigarette  smoking as  the  leading cause of cancer‐related deaths. Sleep apnea  is diagnosed less frequently  in females and can  lead to disturbances  in concentration and attention. Increased girth reduces the ability to be active and exercise on a regular basis. Joint disease and arthritis are common consequences of obesity. It is unclear why female rates are rising at a more rapid pace than men. Insight and action are required for all involved in women’s healthcare.  Despite  the  widespread  impact  and  metabolic  consequences,  effective  treatments  have  remained elusive. New pharmaceuticals have been introduced, but their long term efficacy and side effect profile are  unknown.  The  role  of  new  devices  and  endoscopic  procedures  is  unclear.  Bariatric  surgical procedures  have  the  best  long  term  outcomes  and  increasingly  are  becoming  the  recommended approach for diabetic patients with type 2 diabetes. However, these procedures are invasive, and in all probability, underutilized.    The complexity of weight management and why  logical approaches often fail will be discussed. Future 

directions and their impact on female health will be discussed. 

 Learning  Objectives:  At  the  conclusion  of  this  course,  the  clinician  will  be  able  to:  1)  Discuss  the complexity of obesity management  and why behavioral  approaches have not been  very  effective; 2) Explain the effect of obesity on women’s health and what options exist for improvement; 3) formulate a way  to  approach  and  encourage  obese  patients  to  incorporate  weight  reduction  into  their  overall healthcare plan; and 4) explain how obesity impacts and alters women’s health related to gynecology. 

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PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop (listed in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* R. Edward Betcher* Amber Bradshaw Speakers Bureau: Myriad Genetics Lab Other: Proctor: Intuitive Surgical Sarah L. Cohen Consultant: Olympus Erica Dun* Joseph (Jay) L. Hudgens Contracted Research: Gynesonics Frank D. Loffer, Medical Director, AAGL* Suketu Mansuria Speakers Bureau: Covidien Linda Michels, Executive Director, AAGL* Mitchell S. Roslin Consultant: Covidien, Ethicon Endo-Surgery Contracted Research: Cardiodx, Medtronic Karen C. Wang* Johnny Yi* SCIENTIFIC PROGRAM COMMITTEE Sawsan As-Sanie Consultant: Myriad Genetics Lab Jubilee Brown* Aarathi Cholkeri-Singh Consultant: Smith & Nephew Endoscopy Speakers Bureau: Bayer Healthcare Corp., DySIS Medical, Hologic Other: Advisory Board: Bayer Healthcare Corp., Hologic Jon I. Einarsson* Suketu Mansuria Speakers Bureau: Covidien Andrew I. Sokol* Kevin J.E. Stepp Consultant: CONMED Corporation, Teleflex Stock Ownership: Titan Medical Karen C. Wang* FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). Mitchell S. Roslin Consultant: Covidien, Ethicon Endo-Surgery Contracted Research: Cardiodx, Medtronic Content Reviewer has no relationships. Asterisk (*) denotes no financial relationships to disclose.

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The Rising Rate of Female Obesity and

Its Impact

Mitchell Roslin MD FACS, FASMBSChief of Bariatric and Metabolic SurgeryLenox Hill HospitalNorthern Westchester Hospital CenterProfessor of SurgeryHofstra Northwell School of Medicine

Disclosures

Consultant: Medtronic, Ethicon Endo-Surgery

Contracted Research: Cardiodx, Medtronic

Objective

Discuss the rising rate of female obesity and its impact.

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Ethnic Disparity

Doc. No. 3592 Rev. 2

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1998

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 1998, 2006

(*BMI 30, or about 30 lbs. overweight for 5’4” person)

20061990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

ToxicEnvironoment 1967Priceofcornfixed 1982sevencountries

study“FatisBad”Carbohydratesarefine

Doescigarettecessationplayarole?

Issugartoxic? RobertLustig MD

“FructoseisEthanolwithouttheBuzz!”

Absenceoffiberindiet

Map of Diabetes

Doc. No. 3592 Rev. 2

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Epigenics

Childrenofobesemothersatgreaterriskofearlyheartdeath

asadults

BMJ August 2013

BMI>30 1950 = 28500 woman and 37709 offspring

6551 deaths

35% greater overall mortality

29% greater chance of hospital admission for heart disease

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Metabolic Syndrome

Doc. No. 3592 Rev. 2

EnergyRegulation

• Afferentpathway:ghrelin,PYY,insulin,leptin

• Hypothalamus• Efferentpathway:sympatheticvsparasympathetic

• Obesity=anybreakdowninnegativefeedbacksystemforenergybalance

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Hormonal Changes

Leptin

Insulin

Estrogen and androgens

Growth Hormone

Cortisol

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Does Obesity cause Diabetes?

Most diabetics are obese

Most obese people are not diabetic

Prevalence of diabetes increases with BMI to certain point

Largest Patients are not diabetic

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PCOS

Doc. No. 3592 Rev. 2

Surgery for Diabetes May Be Better Than Standard Treatment

By DENISE GRADYPublished: NY Times March 26, 2012

Change in Diet

Weight Loss

IncretinEffect

Change inPeripheral Insulin Resistance

Resolution Rates

DS + +++ ++ ++ 95%

GastricBypass

+ ++ ++ + 75%

Sleeve Gastrectomy

+ ++ ++ + 70%

Lap-Band + + - - 40%

Obesity and Sexual Function

Leads to early puberty in females, delayed in males

Waist size varies inversely with testosterone

Decrease FSH,SHBG, inhibin B

Each 3 pt rise in BMI reduces couples fertility by 10%

Infertility

Anovulation secondary to insulin resistance

BMI>30 170% increase in anovulation

PCOS and increased androgens, inverted LH and FSH

If infertile, treatments far less successful

Doc. No. 3592 Rev. 2

Risks of Pregnancy

Gestational Diabetes

Hypertension

Preeclampsia

Risk of deficiencies of fe, B12, folate, vit D and Ca

Increasing risk of C section 50% for BMI>40

Anaestheticcomplications

Birth risks

Trouble breast feeding

Childhood obesity

Doc. No. 3592 Rev. 2

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Obesity and Miscarriage

Poor

quality

eggs

Defective

implantation

secondary

to

insulin

re

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Obesity and Cancer

Elevates hormones such as estrogen increasing chance of breast, endometrial prostate cancer

Patients with cancer who are obese do worse secondary to growth effects of insulin and other hormones

13% of malingnancies

Breast Cancer

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Endometrial Cancer

60% of cases avoided by keeping normal weight and exercise50000 cases annually in USWt loss and loss of body fat seems to be key aspect of treatment

Sleep Apnea

Undiagnosed in morbid obesity

Causes poor sleep, snoring, poor concentration

Bariatric surgery can resolve symptoms, frequently getting people off machines to assist sleep

Obesity and Heart Disease

Bariatric Surgery improves Hypertension

Hypercholesterolemia

Hypertriglyceridemia

Diabetes

Weight loss surgery significantly lowers risk of heart disease based on Framingham scare

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Rising Obesity=Rising Arthritis

Obesity increases the risk of knee replacement by 10 fold Obesity increases the risk of hip replacement by 4 fold

Jassira before and after her duodenal switc

Weight loss surgery allows woman to fulfill her dream of being a momBy Loren Grush Published May 13, 2012

Jassira before and after her duodenal switch.Have converted over 50 bands to switch with results similar to primary.

TRANSPYLORIC SHUTTLE

9

ENDOSPHERE SPEEDBUMPS

valenTx

ValenTx By-pass Sleeve

Weight Loss First in Man

Adjustable Gastric Banding Gastric Bypass (RYGBP)Roux-en-Y Gastric Bypass

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Pyloric PreservationSleeve Gastrectomy and

Duodenal Switch

The Pylorus is the body’s natural flow valve

Keeping the pylorus prevents dumping

May also prevent some nutritional abnormalities

May lead to better long term weight control

Sleeve Gastrectomy

Simplified Duodenal Switch

What is Next?

Cannot do procedures for all

Many things have created an obesogenicenvironment

Our food is our fuel, and can be a constant inflammatory focus

The solutions are not easy or popular and will require infringing on personal choice

What is role of government in chronic disease?

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CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as

the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians

(researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which

recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).

California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws

identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org

Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from

discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national

origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the

program, the importance of the services, and the resources available to the recipient, including the mix of oral

and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.

Executive Order 13166,”Improving Access to Services for Persons with Limited English

Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,

including those which provide federal financial assistance, to examine the services they provide, identify any

need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.

Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every

California state agency which either provides information to, or has contact with, the public to provide bilingual

interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.

~

If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.

A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.

US Population

Language Spoken at Home

English

Spanish

AsianOther

Indo-Euro

California

Language Spoken at Home

Spanish

English

OtherAsian

Indo-Euro

19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%

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