Sponsored by National Lipid Association Comprehensive Cardiometabolic Risk-Reduction Program Phase 2...

Sponsored by National Lipid Association

Comprehensive

Cardiometabolic

Risk-Reduction Program

Comprehensive

Cardiometabolic

Risk-Reduction Program

Phase 22009

Special Considerations for the Special Considerations for the Overweight/Obese PatientOverweight/Obese Patient

Case StudyCase Study

Overview

• A 46-year-old male lawyer is referred by his physician for persistent weight gain and high cardiomyopathy risk

• Patient has hyperlipidemia and hypertension; comorbidities include asthma, attention-deficit/hyperactivity disorder (ADHD), chronic fatigue, and depression

• Family history of obesity, type 1 and 2 diabetes

• Current weight of 305.7 pounds is his highest– Admits poor nutritional habits and a low activity level

• Reports waking up “snorting” from snoring at night– Experiences morning headaches and daytime somnolence


Brain

Central SignalsStimulate

NPYAGRP

GalaninOrexin-A

Dynorphin

Inhibit-MSH

CRH/UCNGLP-ICART

NE5-HT

External FactorsEmotionsFood characteristicsLifestyle behaviorsEnvironmental cues

Peripheral Signals Peripheral Organs

Food Intake

Glucose

CCK, GLP-1, Apo A-IVVagal afferents

Insulin

Leptin

Cortisol

–

–

+

Gastrointestinal tract

Adipose tissue

Adrenal glands

Ghrelin+

The Regulation of Food Intake Is a Complex Process

Zhang Y, et al. Nature. 1994;372:425-432; Schwartz MW, et al. Nature. 2000;404:661-671.

NPY=neuropeptide Y, AGRP=agouti-relatedprotein, α-MSH=alpha-melanocyte-stimulatinghormone, CRH/UCN=corticotropin-releasinghormone/urocortin, GLP-1=glucagon-like peptide-1, CART=cocaine- and amphetamine-regulated transcript, NE=norepinephrine, 5-HT=seratonin, CCK=cholecystokinin, Apo A-IV=apolipoprotein A-IV.

Overview

• Medications – Metoprolol 100-mg BID– Atorvastatin 10-mg QD– Niacin 1500-mg BID– Paroxetine 40-mg QD– Lithium 900-mg QD– Amphetamine/

dextroamphetamine 40-mg QD


Starting Your Investigation

• Look for– Obstructive sleep apnea (OSA)– Medications causing weight-gain – Depression– Metabolic syndrome, prediabetes

The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults . October 2000. NIH Publication No. 00-4084.

Weight GainWeight GainWeight GainWeight Gain

Sleep ApneaSleep ApneaSleep ApneaSleep ApneaDepressionDepressionDepressionDepression

A Vicious Cycle

Clinical PearlClinical Pearl

© 2007 Cardiometabolic Support Network

Drug-Associated Weight-Change Reference

Remember to keep this list in your office!

Medications That May Be Contributing to This Patient’s Excess Body Weight

MAOIs=monoamine oxidase inhibitors, TCAs=tricyclic antidepressants, ACE=angiotensin-converting enzymeMAOIs=monoamine oxidase inhibitors, TCAs=tricyclic antidepressants, ACE=angiotensin-converting enzyme


Laboratory Results

• Glucose: 106 mg/dL

• TC: 184 mg/dL

• HDL-C: 33 mg/dL

• LDL-C: 103 mg/dL

• TG: 240 mg/dL

• Non–HDL-C: 151 mg/dL

• EKG: sinus bradycardia, rate 56

• hs-CRP: 8.2 mg/L=high risk

• A1c: 5.9%

• Creatinine: 1.2 mg/dL

• AST: 27 U/L

• ALT: 43 U/L• eGFR: >60 mL/min

TC=total cholesterol, HDL-C=high-density lipoprotein cholesterol, LDL-C=low-density lipoprotein cholesterol, TG=triglycerides, AST=aspartate aminotransferase, ALT=alanine aminotranferase, hs-CRP=high-sensitivity C-reactive protein


Initial Registered-Dietitian Appointment

• Weight: 305.1 pounds, height: 72 inches, BMI: 41.4 kg/m2, waist: 48 inches

• Former athlete with low activity level

• Volume eater with little sense of satiety “when he gets started”

• Daytime fatigue noted, being treated for ADHD

• Diet– Little fast food/red meat

– Eats before bed and sometimes wakes up in the middle of the night to eat

– Breakfast: nothing, lunch: salad, snack: fruit, dinner: Greek salad with chicken or stir-fry, snack: “bad”

• Plan – Keep food records

– Begin to eat breakfast

– Eat higher lean-protein lunches and dinners and begin to reduce refined carbohydrates

– Goal of 30 minutes of walking/day

ADHD=attention-deficit/hyperactivity disorder, BMI=body mass indexADHD=attention-deficit/hyperactivity disorder, BMI=body mass index


High-frequency telephone- and

web-based nutritional counseling

can be effective ways

to help patients lose weight


Breakfast and Nighttime Eating

• Skipping breakfast can drive nighttime eating– Breakfast=none– Lunch=breakfast– Dinner=lunch– Nighttime snack=dinner

• Nighttime eating drives skipping breakfast

• The cycle continues…


A. Low protein

B. Low fat

C. Low glycemic

Which may be the best diet for someone Which may be the best diet for someone with a lack of satiety?with a lack of satiety?Which may be the best diet for someone Which may be the best diet for someone with a lack of satiety?with a lack of satiety?

ARS QuestionARS Question

Glycemic Index (GI)

• Although data vary, a low-GI meal may reduce subsequent energy intake1

• Cochrane systematic review indicates that decreasing the GI* of a diet may be an effective way to promote weight-loss and improve lipid profiles2

1. Flint A, et al. Am J Clin Nutr. 2006;84:1365-73.2. Thomas DE, et al. Cochrane Database Syst Rev. 2009;(1):CD005105.pub2.1. Flint A, et al. Am J Clin Nutr. 2006;84:1365-73.2. Thomas DE, et al. Cochrane Database Syst Rev. 2009;(1):CD005105.pub2.

*GI=area under the curve (AUC) of the 2-hour blood glucose response curve divided by the AUC of an equal amount of glucose, multiplied by 100Low GI food/meal = 55 or less

*GI=area under the curve (AUC) of the 2-hour blood glucose response curve divided by the AUC of an equal amount of glucose, multiplied by 100Low GI food/meal = 55 or less

Diet: What Is Most Important?

Calorie restriction, with high

macronutrient quality*

*High quality indicates more than 5 servings of fruits and vegetables/day, lean protein sources including some vegetarian sources, nuts, healthy oils, nonfat dairy products, whole grains, low in sweets and refined carbohydrates, low in fat

*High quality indicates more than 5 servings of fruits and vegetables/day, lean protein sources including some vegetarian sources, nuts, healthy oils, nonfat dairy products, whole grains, low in sweets and refined carbohydrates, low in fat


Favorable Option for This Patient

• Low refined-carbohydrate diet with increased fiber intake– Patient has prediabetes– Rapid weight-loss is desirable– Patient’s snacks tend to be refined carbohydrates– Lower refined-carbohydrates reduce hunger in some

patients– Higher fiber associated with satiety

• Higher protein intake– Protein increases satiety– Lean protein has little fat and saturated fat, making it a

healthy option for weight loss

Practical Tips:Increasing Fiber and Lean Protein

• Fiber– Fiber One® bran cereal

• Sprinkle it on low-fat yogurt as a bedtime snack– Whole grains, fruits, and vegetables

• Lean protein– Ham, turkey, and roast beef are the leanest sandwich

meats• Have 1/2 sandwich, but double the thickness

– Carnation® Instant Breakfast® No Sugar Added with skim milk=inexpensive, low-GI meal replacement

– Modified pastas that are no longer “refined carbohydrates”• Barilla® PLUS® (2-cups cooked)=17-g protein, 7-g fiber, 360-

mg omega-3 fatty acid

Initial MD Appointment

• Weight: 305.7 lbs, height: 72 inches, BMI: 41.5 kg/m2, blood pressure: 138/90, heart rate: 68 bpm, waist: 48 inches

• Patient is at his highest weight – Several prior weight-loss attempts: no significant progress,

has been steadily gaining weight– Admits poor nutritional habits and a low activity level

• Reports waking up “snorting” from snoring at night– Has morning headaches and daytime somnolence

• Food records show nighttime eating pattern, with large quantities consumed after 6:00 PM


• Medications– Metoprolol 100-mg BID– Atorvastatin 10-mg QD– Niacin 1500-mg BID– Paroxetine 40-mg QD– Lithium 900-mg QD– Amphetamine/dextroamphetamine 40-mg QD

• Action plan – Reinforce importance of continued dietitian visits– Sleep study to evaluate for obstructive sleep apnea– Stop metoprolol; initiate ramipril, titrate ↑ to 5-mg BID– Begin metformin ER 500-mg QD, with goal to increase


What if β-Blockers Are Necessary?

If a If a ββ-blocker is necessary as part of a -blocker is necessary as part of a

multi-agent antihypertensive regimen, an multi-agent antihypertensive regimen, an

agent that does not aggravate insulin agent that does not aggravate insulin

resistance (eg, carvedilol) may be a resistance (eg, carvedilol) may be a

favorable choicefavorable choice


Metformin is appropriate for use in patients with IFG, IGT, and

A. A1c ≥5.0%

B. Hypertension

C. BMI ≥35 kg/m2

D. Family history of diabetes in first-degree relative

According to the 2007 ADA Consensus Statement on According to the 2007 ADA Consensus Statement on impaired fasting glucose (IFG) and impaired glucose impaired fasting glucose (IFG) and impaired glucose tolerance (IGT), which of the following is tolerance (IGT), which of the following is notnot true? true?

According to the 2007 ADA Consensus Statement on According to the 2007 ADA Consensus Statement on impaired fasting glucose (IFG) and impaired glucose impaired fasting glucose (IFG) and impaired glucose tolerance (IGT), which of the following is tolerance (IGT), which of the following is notnot true? true?

ADA=American Diabetes Association, BMI=body mass indexADA=American Diabetes Association, BMI=body mass index


Pharmacological Intervention in the Progression to Diabetes: Recent Statements

• ADA 2007 Consensus Statement– Metformin as an adjunct/alternative to lifestyle in

patients with IFG and IGT, and any of the following• <60 years of age, BMI >35 kg/m2, family history of

type 2 diabetes in first-degree relative, ↑ triglycerides, ↓ HDL-C, hypertension, A1C >6.0%

• ACE 2008 Consensus Statement– Metformin or acarbose as an adjunct to lifestyle

in patients with prediabetes at particularly high risk

Nathan DM, et al. Diabetes Care. 2007;30:753-759.American College of Endocrinology Task Force on Pre-Diabetes. Available at: www.aace.com/meetings/consensus/hyperglycemia/hyperglycemia.pdf. Accessed November 1, 2008.

ADA=American Diabetes Association, IFG=impaired fasting glucose, IGT=impaired glucose tolerance, BMI=body mass index, HDL-C=high-density lipoprotein cholesterol, ACE=American College of EndocrinologyADA=American Diabetes Association, IFG=impaired fasting glucose, IGT=impaired glucose tolerance, BMI=body mass index, HDL-C=high-density lipoprotein cholesterol, ACE=American College of Endocrinology

0

10

20

30

40

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enc

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iab

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)

Years

0 1 2 3 4

Placebo

Lifestyle

Metformin

Weight loss

Decrease in risk*

0.1 kg

2.1 kg 31%

5.6 kg 58%

P<0.001 for each comparison.*Decrease in risk of developing diabetes compared to placebo group.

Diabetes Prevention Program Research Group. N Engl J Med. 2002;346:393-403.

Diabetes Prevention ProgramDiabetes Prevention Program

Don’t Forget: Lifestyle Is More Effective Than Metformin

Month 2—MD Visit 2

• Weight: 294.5 lbs, blood pressure: 140/90, heart rate: 64 bpm, waist: 47 inches

• Followed diet very strictly for first few weeks– Now on diet ≈70% of the time– Still skips breakfast

• Patient rescheduled sleep study, reminded of importance by MD– Reports being very fatigued and realizes he eats to stay

awake

• Action plan– Increase metformin 500-mg to BID, eat protein breakfast

instead of skipping the meal


Sleep-Study Results

• Apnea-hypopnea index (AHI) of 57.8– Diagnosis: severe obstructive sleep apnea-

hypopnea syndrome

• Action plan– Began continuous positive airway pressure

(CPAP) treatment with 12 cm H20• Follow-up AHI of 5.0


Many patients won’t tolerate CPAP…

Risk of erectile dysfunction can be a

strong motivator


Month 3—Registered-Dietitian Visit 2

• Weight: 290.6 lbs

• Not eating breakfast – “No time, no interest, not hungry”

• Eating less at night

• Patient hurt his back and is going to physical therapy, but little aerobic activity secondary to fatigue

• Seeing new psychiatrist who will evaluate medical regimen

• Plan – Meal replacements for breakfast– Continue low-glycemic index diet (increase vegetables,

steak only 1x/week)


Meal Replacements

• Important for patients who have– Little time for food

shopping and preparation

– Hit a weight plateau– Persistent difficulty

managing food and social cues related to overeating

• Advantages– Provide adequate and

consistent nutrition as a low-fat, calorie-controlled replacement for 1 or 2 meals per day

– Eliminate food choices and temptations

– Simplify food shopping and preparation

– Convenient to carry and store

*1200–1500 kcal/d diet prescriptionCF=conventional foods; MR-2=replacements for 2 meals, 2 snacks daily; MR-1=replacements for 1 meal, 1 snack daily

15

10

5

0

Time (mo)

Phase 2 Phase 1*

MR-2

0 2 4 6 8 10 12 18 24 30 36 45 51

MR-1

Wei

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oss

(%

)

CF

Fletchner-Mors, et al. Obes Res. 2000;8:399.

Meal Replacements Promote Short- and Long-Term Weight Loss


• Weight: 277.7 lbs (-28 lbs), BMI: 37.7 kg/m2; blood pressure: 130/80, heart rate: 64 bpm, waist: 44 inches

• Now on CPAP at 12 cm H20– Notes that he feels much better, with more energy

and focus

• Since sleep study and CPAP use, psychiatrist decreased lithium to 600-mg QD, paroxetine to 20-mg QD, and amphetamine/ dextroamphetamine to 20-mg QD

DHA/EPA=docosahexaenoic acid/eicosapentaenoic acidDHA/EPA=docosahexaenoic acid/eicosapentaenoic acid


Lab Results• Glucose: 92 mg/dL• TC: 176 mg/dL• HDL-C: 30 mg/dL• LDL-C: 106 mg/dL• TG: 200 mg/dL• Non–HDL-C: 146 mg/dL

• hs-CRP: 3.1 mg/L• A1c: 5.6%

• Creatinine: 1.2 mg/dL• AST: 25 U/L• ALT: 40 U/L

TC=total cholesterol, HDL-C=high-density lipoprotein cholesterol, LDL-C=low-density lipoprotein cholesterol, TG=triglycerides, hs-CRP=high-sensitivity C-reactive protein, AST=aspartate aminotransferase, ALT=alanine aminotranferase



A. Increase statin dosage

B. Switch to a different statin

C. Add a fibrate

D. Discontinue niacin and add omega-3 FAs

Which of the following would you be most Which of the following would you be most likely to consider as part of the action plan for likely to consider as part of the action plan for this visit?this visit?

Which of the following would you be most Which of the following would you be most likely to consider as part of the action plan for likely to consider as part of the action plan for this visit?this visit?


TC=total cholesterol, HDL-C=high-density lipoprotein cholesterol, LDL-C=low-density lipoprotein cholesterol, TG=triglycerides, hs-CRP=high-sensitivity C-reactive protein, AST=aspartate aminotransferase, ALT=alanine aminotranferase


Action plan • Discontinue niacin• Start omega-3 (DHA/EPA) fatty acids (FA) 2000-mg QD, to BID• Increase metformin to 850-mg BID


Due to the negative effect of niacin on glucose control

and insulin resistance1,2, omega-3 fatty acids may be a

preferred alternative in patients at risk for diabetes*

Clinical Pearl

*Reflects opinion of program Steering Committee.*Reflects opinion of program Steering Committee.

1. Vittone F, et al. J Clin Lipidol. 2007;1:203-210. 2. Goldberg RB, et al. Mayo Clin Proc. 2008; 83:470-8.1. Vittone F, et al. J Clin Lipidol. 2007;1:203-210. 2. Goldberg RB, et al. Mayo Clin Proc. 2008; 83:470-8.

Month 6—Registered-Dietitian Visit 3

• Weight: 274.6 lbs

• Patient has been doing well with breakfast meal replacements, but is bored with diet and feels he has hit a weight plateau

• Plan – Congratulate him on losing 30 lbs! – Continue low-glycemic index diet, but brainstorm

alternative breakfast and snack options – Food records 3 days/week, self-monitor weight

every day for next 2 weeks– Reinforce need for physical activity



• Weight: 270.7 lbs (-35 lbs [-11%]), blood pressure: 124/82, heart rate: 68 bpm, waist: 43 inches

• Current meds: atorvastatin 10-mg QD, metformin 850-mg BID, omega-3 fatty acids (DHA/EPA) 2000-mg BID, ramipril 5-mg BID, amphetamine/dextroamphetamine 20-mg QD, paroxetine 20-mg QD, lithium 600-mg QD

• Using CPAP regularly and has good energy level

• Fair compliance to diet secondary to stress/family– Has some night eating, but generally minimizing sugar and

carbohydrates

• He now feels active enough to exercise and is walking 20 min/day 4x/week


Month 8—MD Visit 4, Laboratory Results


• TC: 157 mg/dL

• HDL-C: 42 mg/dL

• LDL-C: 91 mg/dL

• TG: 120 mg/dL

• Non–HDL-c: 115 mg/dL

• A1c: 5.2%

• hs-CRP: 1.2 mg/LTC=total cholesterol, HDL-C=high-density lipoprotein cholesterol, LDL-C=low-density lipoprotein cholesterol, TG=triglycerides, hs-CRP=high-sensitivity C-reactive protein


Month 8—MD Visit 4, Action Plan

• Psychiatrist stopped lithium, reduced paroxetine to 10-mg QD and reduced amphetamine/dextroamphetamine to 10-mg QD

• Continue metformin 850-mg BID and use of CPAP

• Prescribe exercise regimen


• In addition to

lifestyle factors,

biology favors

weight regain

Eckel RH. N Engl J Med. 2008;358:1941-1950.Eckel RH. N Engl J Med. 2008;358:1941-1950.


A. 60

B. 120

C. 180

D. >300

US Department of Health and Human Services. Available at: http://www.health.gov/paguidelines/guidelines/default.aspx. Accessed February 6, 2009.US Department of Health and Human Services. Available at: http://www.health.gov/paguidelines/guidelines/default.aspx. Accessed February 6, 2009.

According to the US Department of Health and According to the US Department of Health and Human Services 2008 guidelines, how many minutes Human Services 2008 guidelines, how many minutes per week of moderate-intensity exercise do per week of moderate-intensity exercise do manymany people need to maintain their weight after a people need to maintain their weight after a significant amount of weight loss?significant amount of weight loss?

According to the US Department of Health and According to the US Department of Health and Human Services 2008 guidelines, how many minutes Human Services 2008 guidelines, how many minutes per week of moderate-intensity exercise do per week of moderate-intensity exercise do manymany people need to maintain their weight after a people need to maintain their weight after a significant amount of weight loss?significant amount of weight loss?


Although caloric restriction is the key

to weight loss, regular physical

activity is crucial to maintaining a

lower body weight


National Weight Control Registry: Cardinal Behaviors of Successful Long-Term Weight Management

• Self-monitoring– Diet: record food intake daily, limit certain foods or food

quantity– Weight: check body weight >1x/week

• Low-calorie, low-fat diet– Total energy intake: 1300–1400 kcal/day– Energy intake from fat: 20%–25%

• Eat breakfast daily

• Regular physical activity: 2500–3000 kcal/week (eg, walk 4 miles/day)

Klem, et al. Am J Clin Nutr. 1997;66:239. McGuire, et al. Int J Obes Relat Metab Disord.1998;22:572.

• Look for sleep apnea and treat it

• Get your patients off drugs that cause obesity (when possible)

• Consider insulin sensitizers

• Assess medications for aggravation of comorbidities

• Ask patients how well they are sticking to their intended lifestyle changes

Key Learnings: Medical

• Adapt the diet to your patient

• Inform patients that breakfast is associated with weight loss/lower body-weight

• Encourage self-monitoring– Food records– Regular “weigh-ins”

• Reinforce that exercise is critical for the maintenance of weight loss

Key Learnings: Behavioral

Laboratory Test Results• TC: 184 mg/dL• HDL-C: 33 mg/dL• LDL-C: 103 mg/dL• TG: 240 mg/dL

• Non–HDL-C: 151 mg/dL


• A1c: 5.9%• hs-CRP: 8.2 mg/L

At the initial clinical presentation, would this patient have been a candidate for bariatric surgery?

• Weight: 305.7 lbs, BMI: 41.5 kg/m2, waist: 48 inches, blood pressure: 138/90, heart rate: 68 bpm

• Patient at his highest weight and gaining– Several weight-loss attempts without significant progress

• Hyperlipidemia, hypertension, asthma, attention-deficit/hyperactivity disorder, fatigue, depression, obstructive sleep apnea

• Family history of obesity, type 1 and 2 diabetes

BMI=body mass indexBMI=body mass index

Bariatric Surgery

• Indications– BMI >40 kg/m2 or BMI 35–39.9 kg/m2 and life-

threatening cardiopulmonary disease, severe diabetes, or lifestyle impairment

– Failure to achieve adequate weight-loss with nonsurgical treatment

• Contraindications– History of noncompliance with medical care– Certain psychiatric illnesses: personality disorder,

uncontrolled depression, suicidal ideation, substance abuse

– Unlikely to survive surgeryAdapted from www.obesityonline.org.NIH Consensus Development Panel. Ann Intern Med. 1991;115:956.

Surgeon experience is the single best

predictor of success

To locate an ASMBS Center of Excellence

http://www.surgicalreview.org/

ASMBS=American Society of Metabolic and Bariatric Surgery. ASMBS=American Society of Metabolic and Bariatric Surgery.


A. It has not yet been associated with a significant improvement in overall mortality

B. At 10-years postprocedure, it is associated with a decrease in the incidence of hypertension

C. At 10-years postprocedure, over 1/3 of patients with diabetes at baseline no longer had the disease

Which of the following is true about the Which of the following is true about the effects of bariatric surgery?effects of bariatric surgery?Which of the following is true about the Which of the following is true about the effects of bariatric surgery?effects of bariatric surgery?


Bariatric Surgery: Long-Term Effects on Weight and Cardiovascular Risk Factors

• Prospective, controlled intervention trial of 4047 obese subjects (age=48 Prospective, controlled intervention trial of 4047 obese subjects (age=48 years, BMI=41 kg/myears, BMI=41 kg/m22); gastric surgery* vs conventional treatment); gastric surgery* vs conventional treatment

• At 10 yearsAt 10 years– Weight change—surgery: Weight change—surgery: 16.1%16.1%– Weight change—control: Weight change—control: 1.6% (1.6% (PP<0.001)<0.001)– Lower incidence of diabetes, hypertriglyceridemia, and hyperuricemia Lower incidence of diabetes, hypertriglyceridemia, and hyperuricemia

((PP<0.05 for each)<0.05 for each)

Sjostrom L, et al. N Engl J Med. 2004;351:2683-2693.

Hypertri-Hypertri-glyceridemiaglyceridemia

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Low HDLLow HDLCholesterolCholesterol

5353

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DiabetesDiabetes

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HypertensionHypertension

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HyperuricemiaHyperuricemia

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ControlControl

SurgerySurgery

*Banding, vertical-banded gastroplasty, gastric bypass†P≤0.001‡P=0.02

‡

†

†

†

†

Swedish Obese Subjects StudySwedish Obese Subjects StudySwedish Obese Subjects StudySwedish Obese Subjects Study

YearsYearsYearsYears

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BandingBandingBandingBanding

Vertical-Banded GastroplastyVertical-Banded GastroplastyVertical-Banded GastroplastyVertical-Banded Gastroplasty

Gastric BypassGastric BypassGastric BypassGastric Bypass

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PP=0.04=0.04PP=0.04=0.04

Sjostrom L, et al. N Engl J Med. 2007;357:741-752.

*Surgical group vs control group at 16 years

Swedish Obese Subjects StudySwedish Obese Subjects StudySwedish Obese Subjects StudySwedish Obese Subjects Study

• Up to 16 years follow-upUp to 16 years follow-up• Overall mortalityOverall mortality– Hazard ratio*=0.76 (95% CI: 0.59–0.99), Hazard ratio*=0.76 (95% CI: 0.59–0.99), PP=0.04=0.04

Bariatric Surgery: Long-Term Weight Loss and Decreased Mortality

• Advantages– “Forced” lifestyle changes– Improved cardiometabolic risk-factors– Decrease in diabetes

• Both recovery and incidence

– Decrease in mortality

• Pitfalls– Surgical complications– “Forced” lifestyle changes– Patients can “get around” the surgery

Key Learnings: Bariatric Surgery

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