The Obesity Epidemic The Obesity Epidemic John Ganser, MD, FACS - - PDF document

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John Ganser, MD, FACS John Ganser, MD, FACS

www.westernbariatricinstitute.com

The Obesity Epidemic The Obesity Epidemic

The Obesity Epidemic - Outline The Obesity Epidemic - Outline

• Statistics of the Epidemic
• Magnitude of the problem
• Mechanisms of Obesity
• Metabolic Disease
• Comorbid conditions associated and their

effect on mortality

• Effect of weight loss on comorbid

conditions and mortality

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What Is Morbid Obesity? What Is Morbid Obesity?

• A chronic, life-threatening disease.

Recognized as a disease by AMA in 2013

• Excessive body fat accumulation resulting

in a negative effect on health

• BMI > 30 kg/m2
• Risk factor for 30+ medical conditions.
• Medical, psychological, social, physical

and economic impact.

Health Risks of Obesity Health Risks of Obesity

• Obesity is measured by a formula called

body mass index (BMI) weight in kg/height m2.

• A healthy BMI is about 18-25.
• A BMI of 30 or more signals obesity. A BMI
• f 35 or more reflects severe (morbid)
• besity.

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Body Mass Index and Body Fat Body Mass Index and Body Fat

Body Mass Index (BMI)

• Measures obesity

based on weight and height

Height (ft/in)

4’9” 4’11 ” 5’1” 5’3” 5’5” 5’7” 5’9 ” 5’11 ” 6’1 ” 6’3”

154 33

31 29 27 26 24 23 22 20 19

165 36

33 31 29 28 26 24 23 22 21

176 38

36 33 31 29 28 26 25 23 22

187 40

38 35 33 31 29 28 26 25 24

198 43

40 37 35 33 31 29 28 26 25

209 45

42 40 37 35 33 31 29 28 26

220 48

44 42 39 37 35 33 31 29 28

231 50

47 44 41 39 36 34 32 31 29

243 52

49 46 43 40 38 36 34 32 30

254 55

51 48 45 42 40 38 35 34 32

265 57

53 50 47 44 42 39 37 35 33

276 59

56 52 49 46 43 41 39 37 35

287 62

58 54 51 48 45 42 40 38 36

298 64

60 56 53 50 47 44 42 39 37

309 67

62 58 55 51 48 46 43 41 39

320 69

64 60 57 53 50 47 45 42 40

Weight (lbs)

Weight Category BMI (kg/m2) Healthy Weight 18.5-24.9 Overweight 25-29.9 Obese 30-34.9 Severely Obese 35-39.9 Morbidly Obese ≥40

• Please note BMI does not distinguish between fat and muscle. A heavily muscled person could have a BMI in excess of 25 without having any

increased health risks.

Classification of Obesity Classification of Obesity

Clinical Terms Used to Describe Various Levels of Body Fat

Normal Weight

(BMI* 18.5 to 24.9)

Overweight

(BMI 25 to 29.9)

Obese

(Class I)

(BMI 30 to 34.9)

Obese

(Class II)

(BMI 35 to 39.9 )

Extremely Obese

(Class III)

(BMI 40 or more)

• 1. National Institutes of Health/National Heart, Lung and Blood Institute Clinical Guidelines Evidence Report. NIH Publication 98-4083, September 1998.

* BMI (Body Mass Index): A measurement of an individual’s weight in relation to height (kg/m2).

AS1

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Amy.Sauer, 10/1/2007

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The Obesity Epidemic – U.S. The Obesity Epidemic – U.S.

• More than 69% of adults are overweight or obese
• 34.9% of U.S. adults are obese (BMI > 30)
• 78.6 million people
• 6.4% of adults are morbidly obese (BMI>40)
• 32% of children are overweight or obese (2-19)
• 17% are obese
• 365,000 obesity-related deaths occur annually

NHANES National Health and Nutrition Examination Survey 2011-2012

The obesity Epidemic -Worldwide

• 3.4 million deaths worldwide
• Worldwide increase 28.8% to 36.9% in men BMI>30
• Worldwide increase 29.8% to 38.0% in women BMI >30
• Prevalence in children 23.8% boys, 22.6% girls
• No nation has reported success in reducing the prevalence of
• besity in 33 years

1980-2013 Global Burden of Disease Study

The Lancet, Volume 384, issue 9945, P766-781, 30 Aug 2014

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The Obesity Epidemic – Economic Impact The Obesity Epidemic – Economic Impact

• Total medical cost for obesity $168 billion

(1998 $78.5 billion)

• 9.1% of annual spending on medical care
• Individual annual medical cost $1,429 higher

than normal weight (42% Increase)

• 80% higher prescription drug costs than for

normal weight individuals

Health Conditions Related “Comorbidities” Health Conditions Related “Comorbidities”

• Heart Disease
• Type 2 Diabetes Mellitus
• Hypertension
• Strokes
• Certain types of Cancer

– Endometrial – Breast – Prostate – Colon

• Dyslipidemia
• Gallbladder disease
• Sleep apnea
• Asthma
• Reduced fertility
• Osteoarthritis

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“Comorbidities” (continued) “Comorbidities” (continued)

• Low-back and disk

disease

• Pulmonary emboli
• Obesity hypoventilation
• Pulmonary

hypertension

• Gout
• Depression
• Urinary-stress

incontinence

• Gastroesophageal

reflux disease

• Liver and biliary

gallstones

• Soft tissue

infections

• Early death

Pulmonary disease

abnormal PFTs

• bstructive sleep apnea

hypoventilation syndrome

Non-alcoholic fatty liver disease

steatosis steatohepatitis cirrhosis Cardio/Metabolic Syndrome diabetes (80% type 2) dyslipidemia hypertension metabolic syndrome

Gynecologic abnormalities

abnormal menses infertility polycystic ovarian syndrome stress incontinence

Osteoarthritis Skin Gall bladder disease Cancer (42% Breast/Colon)

breast, uterus, cervix colon, esophagus, pancreas kidney, prostate

Phlebitis

venous stasis

Gout

Obesity Impacts Nearly Every Organ System Obesity Impacts Nearly Every Organ System

Depression Stroke GERD Severe pancreatitis

Reference 5

Premature Death

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Fact Fact

An adult with a BMI of 35 or more has a 33% chance of living to age 65 as that of a normal weight person.

Relationship between BMI and Health Risk Relationship between BMI and Health Risk

• Diabetes
• Hypertension
• Sleep apnea
• Depression
• Joint pain
• Infertility
• Cancer
• GERD
• Asthma

Calle EE, Michael MJ, Petrelli JM, et al. Body-mass index and mortality in a prospective cohort of US adults. N Eng J Med. 1999;341(15):1097-105.

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Berrington de Gonzalez A, Hartge P, Cerhan JR, et al. (December 2010). "Body-mass index and mortality among 1.46 million white adults". N. Engl. J. Med. 363 (23): 2211–9.

Relative Risk of Obesity

Berrington de Gonzalez A, Hartge P, Cerhan JR, et al. (December 2010). "Body-mass index and mortality among 1.46 million white adults". N. Engl. J. Med. 363 (23): 2211–9.

Relative Risk of Obesity

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Prevalence of Self-Reported Obesity Am ong U.S. Adults by State and Territory Prevalence of Self-Reported Obesity Am ong U.S. Adults by State and Territory

 The data were collected through the

Behavioral Risk Factor Surveillance System (BRFSS), an ongoing, state-based, telephone interview survey conducted by state health departments with assistance from CDC.

 Obesity: Body Mass Index (BMI) of 30 or

higher.

1985 Obesity* Trends Among U.S. Adults

*BMI > 30 or ~ 30 lbs overweight for 5’4” person

1985 Obesity* Trends Among U.S. Adults

*BMI > 30 or ~ 30 lbs overweight for 5’4” person

No Data <10% 10%–14%

Source: BRFSS, CDC

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1991 Obesity* Trends Among U.S. Adults

*BMI > 30 or ~ 30 lbs overweight for 5’4” person

1991 Obesity* Trends Among U.S. Adults

*BMI > 30 or ~ 30 lbs overweight for 5’4” person

No Data <10% 10%–14% 15%–19%

Source: BRFSS, CDC

1993 Obesity* Trends Among U.S. Adults

*BMI > 30 or ~ 30 lbs overweight for 5’4” person

1993 Obesity* Trends Among U.S. Adults

*BMI > 30 or ~ 30 lbs overweight for 5’4” person

No Data <10% 10%–14% 15%–19%

Source: BRFSS, CDC

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1996 Obesity* Trends Among U.S. Adults

*BMI > 30 or ~ 30 lbs overweight for 5’4” person

1996 Obesity* Trends Among U.S. Adults

*BMI > 30 or ~ 30 lbs overweight for 5’4” person

No Data <10% 10%–14% 15%–19%

Source: BRFSS, CDC

No Data <10% 10%–14% 15%–19% ≥20

1999 Obesity* Trends Among U.S. Adults

*BMI > 30 or ~ 30 lbs overweight for 5’4” person

1999 Obesity* Trends Among U.S. Adults

*BMI > 30 or ~ 30 lbs overweight for 5’4” person

Source: BRFSS, CDC

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2002 Obesity* Trends Among U.S. Adults

*BMI > 30 or ~ 30 lbs overweight for 5’4” person

2002 Obesity* Trends Among U.S. Adults

*BMI > 30 or ~ 30 lbs overweight for 5’4” person

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

Source: BRFSS, CDC

2004 Obesity* Trends Among U.S. Adults

*BMI > 30 or ~ 30 lbs overweight for 5’4” person

2004 Obesity* Trends Among U.S. Adults

*BMI > 30 or ~ 30 lbs overweight for 5’4” person

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

Source: BRFSS, CDC

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2007 Obesity* Trends Among U.S. Adults

*BMI > 30 or ~ 30 lbs overweight for 5’4” person

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

Source: BRFSS, CDC

2010 Obesity* Trends Among U.S. Adults

*BMI > 30 or ~ 30 lbs overweight for 5’4” person

2010 Obesity* Trends Among U.S. Adults

*BMI > 30 or ~ 30 lbs overweight for 5’4” person

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Prevalence* of Self-Reported Obesity Am ong U.S. Adults by State and Territory, BRFSS, 2011 Prevalence* of Self-Reported Obesity Am ong U.S. Adults by State and Territory, BRFSS, 2011

CA MT ID NV UT AZ NM WY WA OR CO NE ND SD TX OK KS IA MN AR MO LA MI IN KY IL OH TN MS AL WI PA WV SC VA NC GA FL NY VT ME HI AK PR GUAM NH MA RI CT NJ DE MD DC

15%–<20% 20%–<25% 25%–<30% 30%–<35% ≥35%

Prevalence* of Self-Reported Obesity Am ong U.S. Adults by State and Territory, BRFSS, 2013 Prevalence* of Self-Reported Obesity Am ong U.S. Adults by State and Territory, BRFSS, 2013

CA MT ID NV UT AZ NM WY WA OR CO NE ND SD TX OK KS IA MN AR MO LA MI IN KY IL OH TN MS AL WI PA WV SC VA NC GA FL NY VT ME HI AK NH MA RI CT NJ DE MD DC PR GUAM

15%–<20% 20%–<25% 25%–<30% 30%–<35% ≥35%

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Prevalence* of Self-Reported Obesity Am ong U.S. Adults by State and Territory, BRFSS, 2 0 1 3 Prevalence* of Self-Reported Obesity Am ong U.S. Adults by State and Territory, BRFSS, 2 0 1 3

Summary

 No state had a prevalence of obesity less than 20%.  7 states and the District of Columbia had a prevalence of

• besity between 20% and <25%.

 23 states had a prevalence of obesity between 25% and

<30%.

 18 states had a prevalence of obesity between 30% and

<35%.

 2 states (Mississippi and West Virginia) had a prevalence

• f obesity of 35% or greater.

 The prevalence of obesity was 27.0% in Guam and 27.9% in

Puerto Rico.+

http://www.cdc.gov/obesity/data/prevalence-maps.html *Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be compared to prevalence estimates before 2011.

+ Guam and Puerto Rico were the only US territories with obesity data available on the 2013 BRFSS.

Causes of Obesity Causes of Obesity

• Obesity results from an energy imbalance

Intake of calories > Expenditure

• Body weight is the result of genes,

metabolism, behavior, environment, culture, and socioeconomic status

• People don’t just decide to become
• verweight

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Obesity: A Multifactorial Disease Obesity: A Multifactorial Disease

Genetic Environmental Behavioral

Causes of Obesity Causes of Obesity

• The way we eat has changed dramatically
• Processed foods
• Eat out more
• Sugar filled drinks
• Cheap food is often bad food
• Convenience (‘Fast food’)
• Limited access to healthy options in poor

areas

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Causes of Obesity: Dietary Energy Supply Causes of Obesity: Dietary Energy Supply

1961 2003

"EarthTrends: Nutrition: Calorie supply per capita". World Resources Institute. 2009

Causes of Obesity Causes of Obesity

• Our activities have changed
• Less outdoors play
• More TV, videogames
• Drive everywhere
• Sedentary work environment
• Unsafe to walk/play in inner cities
• Convenience or Inconvenience

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Causes of Obesity Causes of Obesity

• Poorly understood environmental

variables

• Nutrition during fetal development
• Stress
• Sleep deprivation
• Viral infections
• Gut microbial composition

Causes of Obesity Causes of Obesity

• Obesity is a Metabolic Disease

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Metabolic Pathways of Weight Control Metabolic Pathways of Weight Control

The “Fat-o-Stat”

• Built-in mechanisms to maintain stable weight
• Humans biased in favor of storing fat
• Genetic susceptibility - the FTO gene

– 40,000 people’s genomes studied – Carriers of FTO gene (Fxn unknown) 3 kg heavier Therapeutic possibilities for weight reduction?

Metabolic Pathways of Weight Control Metabolic Pathways of Weight Control

THE BRAIN

• The Hypothalamus - Grand Central Station

– Old animal studies:

• Destroy one area » Obesity
• Destroy another » Starvation

Identified as “Satiety” or “Feeding” centers

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Metabolic Pathways of Weight Control Metabolic Pathways of Weight Control

Brain Signals

• Many Substances influence appetite:

– Glucose – Insulin – Cholecystokinin – Leptin 1994 Friedman, Rockefeller Univ. Inherited gene mutation in mice Active in fat cells - made non-functional protein Inject functional Leptin lowered weight by decreasing appetite and increasing energy expenditure

Metabolic Pathways of Weight Control Metabolic Pathways of Weight Control

LEPTIN

• Rare cause of early obesity in humans
• First Fat Cell hormone that reflects energy storage

–  Triglyceride storage -  Leptin production

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Metabolic Pathways of Weight Control Metabolic Pathways of Weight Control

Leptin Resistance

• Most people with obesity have no known genetic

mutations that could explain their condition

• Leptin levels are actually higher than lean

individuals

• “Leptin Resistance” proteins, normally modulate

Leptin signals in brain

• In Obesity, these proteins overcompensate for

high Leptin levels

Metabolic Pathways of Weight Control Metabolic Pathways of Weight Control

Visceral Responses

• Full stomach

– Nerve response via stretch receptors

• Liver

– Energy status transmitted via Vagus nerve

• Gut Hormones

– Insulin - Suppress appetite – CCK - short-term satiety – Peptide PYY - small intestine, short-term satiety

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Metabolic Pathways of Weight Control Metabolic Pathways of Weight Control Grehlin

• Only gut peptide known to  appetite
• Released from stomach before feeding
• Depresses metabolism
• Increases dramatically during weight loss

provoking increased hunger, inability to keep weight off

• Decreases after Bariatric Surgery

Metabolic Pathways of Weight Control Metabolic Pathways of Weight Control Adiponectin

• Produced and excreted exclusively by fat cells
• Improves glucose and lipid processing
• Fasting raises levels in CSF, triggers release of

appetite stimulating peptide NPY

• Decreased circulating levels in Obesity (Leads to

insulin resistance)

• Starvation Signal

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Pulmonary disease

abnormal PFTs

• bstructive sleep apnea

hypoventilation syndrome

Non-alcoholic fatty liver disease

steatosis steatohepatitis cirrhosis Cardio/Metabolic Syndrome diabetes (80% type 2) dyslipidemia hypertension metabolic syndrome

Gynecologic abnormalities

abnormal menses infertility polycystic ovarian syndrome stress incontinence

Osteoarthritis Skin Gall bladder disease Cancer (42% Breast/Colon)

breast, uterus, cervix colon, esophagus, pancreas kidney, prostate

Phlebitis

venous stasis

Gout

Obesity Comorbidities Obesity Comorbidities

Depression Stroke GERD Severe pancreatitis Premature Death

Obesity Comorbidities Obesity Comorbidities

Prevalence of Significant Morbidities per Weight

JAMA 2003

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Comorbidities: The Metabolic Syndrome Comorbidities: The Metabolic Syndrome

• Estimated to impact 47 million U.S. adults
• Presence of 3 or more of the following
• Central obesity (Waist circumference >40” men, >35”

women)

• Elevated fasting triglycerides (>150 mg/dl)
• Low blood HDL cholesterol (<40 men, <50 women)
• High blood pressure (> 130 systolic / 85 diastolic)
• Elevated fasting glucose (> 100 mg/dl or drug Rx)

Comorbidities: The Metabolic Syndrome Comorbidities: The Metabolic Syndrome

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Comorbidities: The Metabolic Syndrome Comorbidities: The Metabolic Syndrome

Pathophysiology of Metabolic Syndrome

Central Obesity

Insulin Resistance Hyper-Insulinemia Dyslipidemia Type 2 Diabetes Hypertension

Heart Disease

Recent studies suggest metabolic syndrome may be an inflammatory state. Complex interaction between genetic, metabolic, and environmental factors

Comorbidities: Obstructive Sleep Apnea Comorbidities: Obstructive Sleep Apnea

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Comorbidities: Obstructive Sleep Apnea Comorbidities: Obstructive Sleep Apnea

• Results in excess daytime sleepiness
• Decreased alertness
• Increased risk of driving accidents
• Increased risk of diabetes and heart disease
• Depression
• Fatty liver disease
• 4.8 times higher risk of cancer mortality

Comorbidities: Obstructive Sleep Apnea Comorbidities: Obstructive Sleep Apnea

Before surgery One year later Morning Headaches Always 18% Sometimes 32% 16% Never 50% 84% Waking Unrefreshed Always 56% 4% Sometimes 24% 31% Never 20% 65% Habitual snoring 82% 14% Sleep apnea 33% 2% Nocturnal choking 24%

Atkinson RL., et al. JAMA, 2000, 283(24): 3236-3243

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Comorbidities: Obstructive Sleep Apnea Comorbidities: Obstructive Sleep Apnea

100 Patients with symptoms of OSA Prospectively evaluation with Polysomnography 13 No OSA 29 Mild 58 Severe

• Severity did not correlate with BMI

Pre and Post-op Epworth Sleepiness Scale, Respiratory Disturbance Index

Rasheid et.al. Obesity Surgery 2003;13 58-61

Comorbidities: Obstructive Sleep Apnea Comorbidities: Obstructive Sleep Apnea

Rasheid et.al. Obesity Surgery 2003;13 58-61

86 77 100 SpO2 23 56 100 RDI 3 14 100 ESS 40 62 100 BMI

Postop

Up to 21 months

Preop n

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Comorbidities: Cancer Comorbidities: Cancer

• Esophagus
• Pancreas
• Colon and rectum
• Breast (After menopause)
• Endometrium
• Kidney
• Thyroid
• Gallbladder

Comorbidities: Cancer Comorbidities: Cancer

• 34,000 new cancer cases in men (4%)
• 50,500 new cancer cases in women (7%)
• As much as 40% of endometrial and

esophageal adenocarcinomas

• An increase in BMI of 5 kg/m2 increases

cancer mortality risk 10%

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Comorbidities: Cancer Comorbidities: Cancer

• Fat tissue produces excess amounts of estrogen
• Increased levels of insulin and IGF-1
• Fat cells produce Adipokines
• Leptin: Promotes cell growth
• Direct and indirect effects on tumor growth regulators
• mTOR, AMP-activated protein kinase
• Increased levels of inflammatory mediators
• Chronic inflammation
• Altered immune response

Mechanisms of cancer in obesity

Comorbidities: Cancer Comorbidities: Cancer

• 13 year follow-up after bariatric surgery showed

significant decrease in incidence of first cancer in women (p=.0009)

• Improved natural killer cell function

Swedish Obesity Study (SOS)

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The Obesity Epidemic- Solutions The Obesity Epidemic- Solutions

• INVOLVES MANY LEVELS
• Change diet
• Drink water
• Increase physical activity
• Limit TV, Video games
• School Health Advisory Council
• Improve food offered to children

The Obesity Epidemic - Solutions The Obesity Epidemic - Solutions

• Employer sponsored programs
• Work site health programs
• Healthy food options
• Health insurance wellness benefits
• Improve access to healthy
• Government sponsored Farmers markets
• Incentivize stores to open in less desirable

areas

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Obesity Treatment Options Obesity Treatment Options

• Diet
• Only 3% to 5% of patients lose an appreciable

amount of weight. Few keep it off.

• Exercise
• Behavioral
• Pharmaceuticals
• Surgery

Obesity Treatment Pyramid Obesity Treatment Pyramid

SURGERY BMI 35+ with comorbidities BMI 40+ PHARMACOTHERAPY BMI 27+ with comorbidities BMI 30+ LIFESTYLE MODIFICATIONS BMI 25+

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Obesity Treatment Options Obesity Treatment Options Obesity Treatment Options: Behavior Obesity Treatment Options: Behavior

Very-low-calorie diet Modified diet plus behaviour therapy Very-low-calorie diet plus behaviour therapy

• 5
• 10
• 15
• 20

5 1

intervention

2 3 4 5 Weight change (kg)

Source: Bray GA, Bouchard C and Jones WPT eds. Handbook of Obesity. New York, NY: Marcel Dekker; 1998:31-40 from data in Wadden TA et. al. Int J Obes 1989;13 Suppl 2:39-46

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High Attrition Rate of Commercial Diet High Attrition Rate of Commercial Diet

Weeks after commencement of program % participating

Obesity Treatment Options– Surgery Obesity Treatment Options– Surgery

• Severe obesity can be treated successfully.
• Bariatric surgery is the standard of care.

“Only surgery has proven effective over the long term for most patients with clinically severe obesity”

• National Institutes of Health Consensus

Development Conference Statement

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Types of Surgery: A Long History Types of Surgery: A Long History

• Restrictive

– Vertical Banded Gastroplasty (VGB) – Gastric Banding (Lap Band) – Vertical Sleeve Gastrectomy

• Malabsorptive

– Jejunoileal Bypass (JIB) – Biliopancreatic Diversion (BPD) – Duodenal Switch – Long Limb Gastric Bypass

• Intermediate

– Roux-en-Y Gastric Bypass (LRYGB)

Most Common Bariatric Procedures Most Common Bariatric Procedures

Adjustable Gastric Banding

Place implantable device around upper most part

• f stomach

Resect approximately 80% of the stomach

Sleeve Gastrectomy

Bypass a portion of the small intestine and create a 15-30cc stomach pouch

Roux-en-Y Gastric Bypass

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Resolution of Comorbidities after Bariatric Surgery Resolution of Comorbidities after Bariatric Surgery

Improved Survival with Surgery Improved Survival with Surgery

1 2 3 4 5 6 7

Average of Control (%) Average of Surgical (%)

• 5 year Follow up
• 6.17% (n=5746) mortality

rate among NON-SURGICAL group (control Group)

• 0.68% (n=1035) mortality

rate among SURGICAL GROUP

• 89% reduction in relative risk
• f mortality in 5 year period

Christou et al. Ann Surg. 2004; 240:416-424

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Bariatric Surgery - Low Incidence of Mortality Bariatric Surgery - Low Incidence of Mortality

*When performed at a Bariatric Surgery Center of Excellence

*

Husband and Wife – 1 Year Post-op Husband and Wife – 1 Year Post-op

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The Obesity epidemic - Conclusions The Obesity epidemic - Conclusions

• Obesity is rapidly increasing worldwide due to a

complex interaction of social, environmental, genetic and metabolic factors

• There are numerous health risks associated with
• besity which lead to a significant reduction in life

expectancy and have a large economic impact on society

The Obesity epidemic - Conclusions The Obesity epidemic - Conclusions

• Comorbid conditions are often under diagnosed

and inadequately treated

• Bariatric surgery is an option when all other

attempts at weight reduction have failed, and provides excellent resolution of most obesity related conditions

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Comorbidity % Improved % Resolved

Dyslipidemia Hypercholesterolemia 33% 63% Hypertension 18% 52-92% Non-Alcoholic fatty Liver Disease 90% (Steatosis) 20% (Fibrosis) 37% (Inflammation) Type II Diabetes Mellitus 17% 83% Metabolic Syndrome N/A 80% Obstructive Sleep Apnea 19% 74-98% GERD 24% 72-98% Gout 14% 77%

Cleveland Clinic Journal of Medicine. 2006, Vol 73. &Source: Schauer et al, “Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Annals of Surgery, 2000

Resolution/Improvement of Comorbidities Resolution/Improvement of Comorbidities

Roux-En-Y Gastric Bypass: Results Roux-En-Y Gastric Bypass: Results

Gastric Bypass provides durable weight control

• Weights fell from preoperative mean of 304.4 lb to

* 192.2 lb. At 1 yr. * 205.4 lb at 5 yr. * 206.5 lb at 10 yr. * 204.7 lb at 14 yr

Poires WJ, Swanson MS MacDonald KG et al. Who would have thought it? An operation proves to be the most effective therapy for adult onset diabetes mellitus. Ann Surg 1995; 222:339-52

N=608 patients

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Resolution / Improvement of Comorbidities Resolution / Improvement of Comorbidities

Source: Schauer et al, “Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Annals of Surgery, 2000

Comorbidity % Improved % Resolved Diabetes 18% 82% Sleep Apnea 19% 74% Gout 14% 72% GERD 24% 72% Hypertension 18% 70% Hyperlipidemia 33% 63%

After Gastric Bypass surgery

WBI Outcomes – Body Mass Index WBI Outcomes – Body Mass Index

**Data includes Western Bariatric Institute gastric bypass and gastric banding patients through 2007.

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WBI Outcomes - Weight WBI Outcomes - Weight

**Data includes Western Bariatric Institute gastric bypass and gastric banding patients through 2007

What A Difference A Year Makes… What A Difference A Year Makes…

Pre-Op Post-Op

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Our Success Stories Our Success Stories

Pre-Op Post-Op

Now It’s Your Turn… Now It’s Your Turn… Audience Question and Answer Session