Obesity Flashcards
Healthcare costs of obesity?
Upto 30% of health care costs
Multifactorial causes of obseity?
- excess calorie
- decreased energy expenditure
- inefficient use of calories
Endocrine causes of obesity?
- Hypothyrodism
- Cushing’s
- Diabetes mellitus
Not all obese people get diabetes, what is the proportion?
20/1000
What is PEDF?
Pigment epithelium derived factor, hormone that can lead to development of T2DM
What is relationship between fat cells and insulin
- Insulin resistance/desensitization (exhausted pancreas) from a protein released by fat cells
- PEDF2
Obesity leading to high BP, how so?
-Must pump more blood through additional blood vessels
Obesity leading to OSA, how so?
- hypoxia, right HF
- blocked airway during sleep, causing shallow breathing or pauses
TRUE or False, obese pt often consider their condition as a greater handicap than deafness, dyslexia, or blindness
TRUE
Obesity implications
HTN, DM2, OSA, Cancer
Infertility, GB disease, psychological
Link between obesity and mortality from cancer?
- higher BMI shows higher mortality
- possible role for estron/estrogen from fat (both men and women)
What is the only weight loss system out there that was proven to work?
- Weight watchers, but 10% EWL at 1yr, 6% at 2 yrs
- Long term success at 5yrs
How much weight do you gain by yourself every 5 years?
- 2-3% every 5 years
- sometime success can be seen as preventing that added weight
NIH Consensus Indications for Bariatric Surgery?
-BMI >40, or >35 with significant comorbidities
-Failed safe non-surgical means of wt loss
(slightly out-dated guidelines)
Contra-indications to bariatric surgery?
- 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)
What is the J curve?
- Higher BMI >40 increases morality risk (about 2.5x higher)
- but BMI
Typical gastric bypass patient?
Avg age 45-50
80-90% women
Most common procedure type in Ottawa?
93% Rouy-en-Y gastric bypass
7% sleeve gastrectomy (success not know yet, 12 yr old only)
Impact on Mortality of gastric surgery (Christou study), at 5 years?
Versus controls, surgical group had
- 4x less cancer
- 6x less CVS related complications
- Mortality 10x less
Adams NEJM, 2007, retrospective cohort for 7 years, findings?
All-cause mortality: 40% Risk Reduction in surgical group vs control. Less CAD (56%), Diabetes (92%), Cancer (60%)
BUT, 58% increase in suicide accidents
Medical impact of weight loss Sx?
95% cure of diabetes
92% cure of HTN
90% cure of CAD, anginal
85% cure Sleep apnea
Contra-indication to sleeve?
Pre-existing GERD, as a sleeve can make it worse
Morbidly obese = BMI?
BMI > 40-49 or >35 with co-morbidities
or >100 lb overweight , or >200% of ideal weight
Superobese BMI?
BMI >50
The bigger you are, the less your estimated weight loss of excess weight (bone, ribs, ligaments, wont shrink)
Overweight BMI?
Obese BMI?
overweight 25-29
Obese 30-39
Referral process in Ontario
Ontario Centralized Referral intake (1 waitlist for whole province)
Who should have bariatric sx, besides NIH 1989 guidelines
Diabetes, very liberal in operating on those
Pre-op work up for bariatric sx?
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)
STOPBang?
SNORE, TIRED, OBSERVED apnea, PREssure (high)
BMI > 35, Age >50
Neck size large (male 17in, female 16in)
Gender = male
OSA risk stratification based on Yes to STOPBang?
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
HbA1C target pre-op for bariatric?
7.5% and below
But answer not clear
Blood work pre-op?
SMA10, LFT’s, INR/PTT, TSH
HbA1C
U/A
Pregnancy test
Upper limit of bypass length?
Not more than 150-175 cm
Otherwise risk a lot of vitamin deficiency, diarrhea
Types of Surgery done at TOH?
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
Reported complications with Gastric Bypass? (4 highlighted ones)
- Gastro-Jejunal stenosis 7.6%
- PE 0.5%
- SBO 4.4% due to internal hernia
- Gastro-jejunal stomal ulcer (typically smokers, NSAIDs) 0.3%
Rate of unplanned readmission to acute inpatient care within 30 days of Bariatric surgery?
Ottawa has highest rate in province of 9%
Database data 2012-2013, 6.3% (versus 9.4% from 2006-07)
What amount of weight reduction is needed to see benefits?
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)
What is obesity
- fatty tissue accumulation from,
- chronic over nutrition, and
- reduced physical activity
