Obesity

Question 1

Healthcare costs of obesity?

Answer 1

Upto 30% of health care costs

Question 2

Multifactorial causes of obseity?

Answer 2

• excess calorie
• decreased energy expenditure
• inefficient use of calories

Question 3

Endocrine causes of obesity?

Answer 3

• Hypothyrodism
• Cushing’s
• Diabetes mellitus

Question 4

Not all obese people get diabetes, what is the proportion?

Answer 4

20/1000

Question 5

What is PEDF?

Answer 5

Pigment epithelium derived factor, hormone that can lead to development of T2DM

Question 6

What is relationship between fat cells and insulin

Answer 6

• Insulin resistance/desensitization (exhausted pancreas) from a protein released by fat cells
• PEDF2

Question 7

Obesity leading to high BP, how so?

Answer 7

-Must pump more blood through additional blood vessels

Question 8

Obesity leading to OSA, how so?

Answer 8

• hypoxia, right HF

- blocked airway during sleep, causing shallow breathing or pauses

Question 9

TRUE or False, obese pt often consider their condition as a greater handicap than deafness, dyslexia, or blindness

Answer 9

TRUE

Question 10

Obesity implications

Answer 10

HTN, DM2, OSA, Cancer

Infertility, GB disease, psychological

Question 11

Link between obesity and mortality from cancer?

Answer 11

• higher BMI shows higher mortality

- possible role for estron/estrogen from fat (both men and women)

Question 12

What is the only weight loss system out there that was proven to work?

Answer 12

• Weight watchers, but 10% EWL at 1yr, 6% at 2 yrs

- Long term success at 5yrs

Question 13

How much weight do you gain by yourself every 5 years?

Answer 13

• 2-3% every 5 years

- sometime success can be seen as preventing that added weight

Question 14

NIH Consensus Indications for Bariatric Surgery?

Answer 14

-BMI >40, or >35 with significant comorbidities
-Failed safe non-surgical means of wt loss
(slightly out-dated guidelines)

Question 15

Contra-indications to bariatric surgery?

Answer 15

• Inability to follow post-op instructions (major psych illness, Down’s syndrome)
• Drug addiction -Age >60 (soft boundaries)
• Prohibitively high medical risk (kidney/cardiac transplant recipt)

Question 16

What is the J curve?

Answer 16

• Higher BMI >40 increases morality risk (about 2.5x higher)

- but BMI

Question 17

Typical gastric bypass patient?

Answer 17

Avg age 45-50

80-90% women

Question 18

Most common procedure type in Ottawa?

Answer 18

93% Rouy-en-Y gastric bypass

7% sleeve gastrectomy (success not know yet, 12 yr old only)

Question 19

Impact on Mortality of gastric surgery (Christou study), at 5 years?

Answer 19

Versus controls, surgical group had

• 4x less cancer
• 6x less CVS related complications
• Mortality 10x less

Question 20

Adams NEJM, 2007, retrospective cohort for 7 years, findings?

Answer 20

All-cause mortality: 40% Risk Reduction in surgical group vs control. Less CAD (56%), Diabetes (92%), Cancer (60%)
BUT, 58% increase in suicide accidents

Question 21

Medical impact of weight loss Sx?

Answer 21

95% cure of diabetes
92% cure of HTN
90% cure of CAD, anginal
85% cure Sleep apnea

Question 22

Contra-indication to sleeve?

Answer 22

Pre-existing GERD, as a sleeve can make it worse

Question 23

Morbidly obese = BMI?

Answer 23

BMI > 40-49 or >35 with co-morbidities

or >100 lb overweight , or >200% of ideal weight

Question 24

Superobese BMI?

Answer 24

BMI >50

The bigger you are, the less your estimated weight loss of excess weight (bone, ribs, ligaments, wont shrink)

Question 25

Overweight BMI?

Obese BMI?

Answer 25

overweight 25-29

Obese 30-39

Question 26

Referral process in Ontario

Answer 26

Ontario Centralized Referral intake (1 waitlist for whole province)

Question 27

Who should have bariatric sx, besides NIH 1989 guidelines

Answer 27

Diabetes, very liberal in operating on those

Question 28

Pre-op work up for bariatric sx?

Answer 28

EKG, CXR
Hpylori serology, if positive - scope with biopsy
Sleep apnea testing if STOPBang screen +ve
Colonoscopy/FOB if >55 (rule out cancer pre-op)

Question 29

STOPBang?

Answer 29

SNORE, TIRED, OBSERVED apnea, PREssure (high)
BMI > 35, Age >50
Neck size large (male 17in, female 16in)
Gender = male

Question 30

OSA risk stratification based on Yes to STOPBang?

Answer 30

Low risk: 0 - 2 Q’s
Intermediate: 3 to 4 Q’s
High risk: 5 - 8 Q’s
or yes to >2 STOP Q’s +male/BMI/neck

Question 31

HbA1C target pre-op for bariatric?

Answer 31

7.5% and below

But answer not clear

Question 32

Blood work pre-op?

Answer 32

SMA10, LFT’s, INR/PTT, TSH
HbA1C
U/A
Pregnancy test

Question 33

Upper limit of bypass length?

Answer 33

Not more than 150-175 cm

Otherwise risk a lot of vitamin deficiency, diarrhea

Question 34

Types of Surgery done at TOH?

Answer 34

1- Proximal gastric bypass
2- Gastric sleeve (60cc to 80cc new stomach are), 60 ideal
3- BPD (bilio-pancreatic diversion) with duodenal switch (marceau)
Not so common

Question 35

Reported complications with Gastric Bypass? (4 highlighted ones)

Answer 35

• Gastro-Jejunal stenosis 7.6%
• PE 0.5%
• SBO 4.4% due to internal hernia
• Gastro-jejunal stomal ulcer (typically smokers, NSAIDs) 0.3%

Question 36

Rate of unplanned readmission to acute inpatient care within 30 days of Bariatric surgery?

Answer 36

Ottawa has highest rate in province of 9%

Database data 2012-2013, 6.3% (versus 9.4% from 2006-07)

Question 37

What amount of weight reduction is needed to see benefits?

Answer 37

10 kg (20lbs)

• decreased HTN, Angina, dyslipidemia, Diabetes
• First 10kg is where you see the most benefit (and so may argue sleeve is the way to go)

Question 38

What is obesity

Answer 38

• fatty tissue accumulation from,
• chronic over nutrition, and
• reduced physical activity