RBH Obesity Pathway Theingi Aung Greg Jones

RBH Obesity Pathway Theingi Aung & Greg Jones RBH 23 rd September 2015

Prevalence of Obesity • Increasing at a epidemic rate globally • 2. 3 billions adults-overweight • 700 millions-clinically obese • Expected to rise further WHO; Obesity and overweight: fact sheet 311

Country* Adult Obesity (%) Adult Overweight (%) Combined Obese and Overweight (%) Brazil 17. 4 33. 6 51. 0 Bulgaria 23. 7 34. 5 58. 2 Canada 18. 4 34. 1 52. 5 Denmark 14. 1 33. 3 47. 4 England 24. 8 37. 1 61. 9 France 15. 0 32. 6 47. 6 Germany 23. 6 36. 5 60. 1 Italy 10. 3 36. 5 46. 8 Mexico 32. 2 39. 1 71. 3 Spain 22. 9 39. 4 62. 3 United States 35. 7 33. 1 68. 8 Adapted from European Association for the Study of Obesity

Prevalence of obesity among adults aged 16+ years Health Survey for England 1993 -2012 (3 -year average)

Prevalence of Obesity • West Berkshire – BMI >50 N= 922 – BMI 40 -50 N= 3559 – BMI 30 -40 N= 2685

Relative risk of health problems associated with obesity Greatly increased (relative risk >>5) Moderately increased (relative risk 2 -3) Diabetes Coronary heart disease Gall bladder disease Osteoarthritis (knees) Hypertension Hyperuricaemia and gout Gastro-oesophageal reflux disease Dyslipidaemia Increased (relative risk 1 -2) Cancer (postmenopausal breast cancer, endometrial cancer, colon cancer, prostate cancer, oesophageal cancer) Breathlessness Low back pain Polycystic ovary syndrome Nonalcoholic fatty liver disease Impaired fertility Sleep apnoea Obstetric complications Increased anaesthetic risk

NBSR Report 2014 -DM outcome

Models of care • Tier 4 - Specialised Complex Obesity Services (including bariatric surgery) • Tier 3 - MDT obesity service to provide an intensive level of input to patients. • Tier 2 - Primary Care with Community Interventions • Tier 1 - Primary Care and Community Advice

Tier 3/4 Specialist Complex Obesity Service at RBH 1. Eligibility criteria 2. Referral 3. MDT assessment and optimisation of medical conditions before surgery 4. Pre-op preparation programme & review 5. Surgical MDT 6. Pre-op clinic 7. Surgery 8. Post surgical care pathway

Clinical Commissioning Policy: Complex and Specialised Obesity Surgery (Tier 4) • BMI > 40 kg/m 2 • BMI >35 kg/m 2 in the presence of other significant diseases • Age <65 yr • There must be formalised MDT led processes for – the screening of co-morbidities – the detection of other significant diseases – The medical evaluation is mandatory prior to entering a surgical pathway. • Morbid/severe obesity has been present for at least five years.

Bariatric surgery for recent onset type 2 diabetes • Consider Bariatric surgery with: – expedited assessment for BMI 35+ and recent onset T 2 DM. – with a BMI of 30 -34. 9 with recent onset T 2 DM – Lower BMI in Asian population with recent onset T 2 DM • as long as they are receiving or will receive assessment in tier 3 service.

Mode of referral • Choose & Book (medical team not surgical) • Letter direct to bariatric team • Referrals from other specialities

Time line of assessment of RBH Obesity pathway for surgery • Medical MDT (Endocrinologist, Specialist dietician, clinical psychologist) BSN-group sessions Baseline 6 -months 10 -12 months • 3 months life style groups secssions (Specialist dietician, clinical psychologist) • Medical investigations & treatment of Co-morbidities; 1: 1 section for intensive input-selective patient • Review by medical MDT clinic (notes) review • medical review, weight target, patient engagement to programme, Low calorie diet pathway • Surgical MDT: Medical team, Surgeons & Anaesthetics 12 -18 months Follow-up • Drop in clinics, Band adjustments, Group supports, Medical reviews RBH Care pathway is available only for patients who want bariatric procedure; no medical pathway is currently not available: Exception: for BMI>50: minimum period of assessment 6 months.

Surgical MDT • Discuss difficult cases and see pre-op patients • Includes: – – – – Consultant Bariatric Surgeon (3) Metabolic Physician/Endocrinologist (1) Consultant Bariatric Anaesthetist (2) Specialist Dietician (2) Bariatric Nurse Specialist (1) Clinical Psychologist with Bariatric interest (2) Specialist Nurse in Endocrine and Bariatric (1) – Surgical Pharmacist with Bariatric Interest (1) – Consultant Radiologist with Gastrointestinal and Bariatric interest (1)

Pre-op Discussion (Nice CG 189) • • • Potential benefits Longer-term implications for surgery Associated risks Complications Peri-operative mortality Consent process in clinic All patients re-discussed at end of clinic and confirmation of surgery agreed

Surgical procedures at RBH • • • Laparoscopic Adjustable Gastric band Laparoscopic Sleeve gastrectomy Laparoscopic Roux-en-y gastric bypass Gastric balloon Revisional Bariatric surgery

Lap-Band

Gastric Bypass

Sleeve Gastrectomy Ghrelin GLP-1 PYY

Post-op care • In hospital: – – – Day of operation – water Day 1 – free fluids Day 2 – discharged home Daily consultant review Due to start an Enhanced recovery programme • On discharge: – All – Multivitamins, LMW heparin (2 week) – Sleeve/bypass • • Ferrous fumerate Calcit D 3 Vitamin B 12 Lansoprazole fast tab (3 months)

Follow-up (Nice CG 189) • Minimum 2 years within the bariatric service, including: – – – – Monitoring nutritional intake and deficiencies Monitoring co-morbidities Medication review Dietary and nutritional assessment Physical activity advice and support Psychological support tailored to the individual Peer support • After discharge from bariatric service: – Annual monitoring of nutritional status and appropriate supplementation – Shared care model of chronic disease

Gastric band follow up • Surgical Clinic – 4 weeks – 4 months • Radiology- first band fill – 6 -8 weeks • Specialist Nurse for band adjustment – – 12 weeks monthly until correct fill 3 months 6 months • Specialist Nurse short notice/rescue clinic

Bypass/sleeve follow up • Surgical clinic: – 4 weeks – 4 months – 12 months – Rescue appointments if needed • Dietician: – 3 monthly in first year – 6 monthly until 2 years Drop in sessions for post-op: monthly at Diabetes centre)

Blood tests • To be performed at patients General Practice • Results to be acted upon by bariatric unit • Band – FBC, U& E, LFT annually • Bypass/Sleeve – FBC, U&E, LFT, Ferritin, Folate, Calcium, Vitamin D, PTH, • 3, 6, 12 months in first year and then annually – Vitamin B 12 • 6, 12 months and then annually – Zinc, copper • Annually

Micronutrient replacement • All patients to buy – Complete A-Z multi-vitamin and mineral • GP to prescribe for sleeve and bypass patients – Calcium and Vit D Combined (Calcit D 3) • daily for life – Vitamin B 12 injection • 3 monthly – Iron Supplement (Ferrous Fumarate) • Daily for life

Time line of assessment of RBH Obesity pathway for surgery • Medical MDT (Endocrinologist, Specialist nurse, Specialist dietician, clinicla psycologist) Baseline 6 -months 10 -12 months • 3 months life style groups secssions (Specialist dietician, clinical psychologist) • Medical investigations & treatment of Co-morbidities; 1: 1 section for intensive input • Review by Endocrinologist/MDT notes clinic • medical review, weight target, patient engagement to programme • Surgical MDT: Medical team, Surgeons & Anaesthetics 12 -18 months Follow-up • Drop in clinics, Band adjustments, Group supports, Medical reviews RBH Care pathway is available only for patients who want bariatric procedure; no medical pathway is currently not available: Exception: for BMI>50: minimum period of assessment 6 months.