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Obesity – Surgical and other interventions Stephen Pollard Consultant Surgeon St James’s University Hospital and Leeds Spire Hospital Cutting Edge Surgery February 2009. Classification by Body Mass Index (BMI; kg/m 2 ). <18 underweight 18-25 desirable 27-30 overweight

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Obesity –

Surgical and other interventions

Stephen Pollard

Consultant Surgeon

St James’s University Hospital and Leeds Spire Hospital

Cutting Edge Surgery

February 2009


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Classification by Body Mass Index(BMI; kg/m2)

  • <18 underweight

  • 18-25 desirable

  • 27-30 overweight

  • 30-35 obese

  • 35-40 with med problems or >40 morbidly obese

  • >50 superobese

  • >60 super-super obese

  • >70 ultra-obese


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The size of the problem in the UK

  • Prevalence of obesity:

    1980 1993 1998 2002 2006

  • Male 6 16 21 24 29

  • Female 8 13 17 21 24

  • Overall, 3% of adults are morbidly obese

  • 30-50,000 deaths attributed to obesity per annum

  • 1.2 million fulfil NICE criteria for surgery


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European Charter on Counteracting Obesity (WHO; 2006)

Recognised surgery as the only effective treatment for morbidly obese patients

Reported European data:

  • 150,000,000 obese adults

  • 15,000,000 obese children

  • 1,000,000 deaths per annum

  • http://www.euro.who.int/Document/E89567.pdf


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The size of the problem worldwide

  • >1 billion people are overweight

  • >Quarter of a billion are obese

  • More people suffer from obesity than from malnutrition


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The cost of obesity

  • In the UK

  • Estimated healthcare costs of

    £6.6 – £7.4 billion per year (NICE, Dec 2006)

  • US - $75 billion


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Socio-economic class

% of adult population with BMI>30

SE class 1 5

Male 11 16

Female 14 28


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The future of bariatric surgery

“Predictions are risky, particularly when made about the future”

Senator Dan Quayle, Former U.S. Vice President


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Obesity in Children

  • 8.5% of 6 year olds are obese

  • 15% of 15 years olds are obese

  • 90% of obese children become obese adults

    But

  • Average intake of calories per meal has remained unchanged since 1945

    So what has changed?

  • Snacking on energy dense high calorie foods between meals and a more sedentary lifestyle

  • 1985 – 80% of children walked or cycled to school

  • 2003 – 5% of children walked or cycled to school

    Dec 2006 – NICE consider children suitable for surgery



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Weight is regulated with great precision. For example, during a lifetime, the average person consumes at least 60 million kcal. A gain or loss of 10Kg, representing approximately 90,000 kcal, involves an error of no more than 0.001%.

The results of adoption and family studies show a heritability of obesity of about 33%. Genetic influences may be more important in determining regional fat distribution than total body fat, particularly the critical visceral fat depot.

The converse of finding that genetic factors only influence a proportion of the variation in body weight means that the environment exerts an enormous influence.


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The issues of obesity during a lifetime, the average person consumes at least 60 million kcal. A gain or loss of 10Kg, representing approximately 90,000 kcal, involves an error of no more than 0.001%.

  • What has history told us?

    Mixed messages


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Idolised as a thing of beauty, prosperity and health during a lifetime, the average person consumes at least 60 million kcal. A gain or loss of 10Kg, representing approximately 90,000 kcal, involves an error of no more than 0.001%.


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A sign of good health during a lifetime, the average person consumes at least 60 million kcal. A gain or loss of 10Kg, representing approximately 90,000 kcal, involves an error of no more than 0.001%.


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Cardiac risk of obesity during a lifetime, the average person consumes at least 60 million kcal. A gain or loss of 10Kg, representing approximately 90,000 kcal, involves an error of no more than 0.001%.

  • Based on Framingham Heart Study

  • Risk of death within study period (26 yrs) increases by: 1% per pound overweight for 30-42 year olds

    2% per pound overweight for 50-62 year olds

    BMI 25-30 equates to 3 years loss of life

    BMI >30 equates to 7 years loss of life

    BMI >40 equates to 15 years loss of life

    BMI > 30 + smoking equates to 13 years loss of life


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Risk of type 2 diabetes during a lifetime, the average person consumes at least 60 million kcal. A gain or loss of 10Kg, representing approximately 90,000 kcal, involves an error of no more than 0.001%.

  • In males – increase waist from <87.5cm to >101.6cm increases risk of type 2 diabetes 12 fold

  • If BMI>25, risk increases 5 fold

  • If BMI>35, risk increases 93 fold


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Obesity Related Comorbidity during a lifetime, the average person consumes at least 60 million kcal. A gain or loss of 10Kg, representing approximately 90,000 kcal, involves an error of no more than 0.001%.

  • Diabetes mellitus

  • Hypertension

  • Dyslipidaemia

  • Some cancers

  • Hypoventilation syndromes (OHS and OSA)

  • Asthma

  • Gastro-oesophageal Reflux

  • Gallstones and NAFLD

  • Osteoarthritis

  • Abdominal wall herniae

  • Neurological disorders

  • Androgenisation, polycystic ovaries and infertility

  • Psoriasis

  • Venous stasis and varicose veins

  • Affective disorders


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Pickwickian Syndrome during a lifetime, the average person consumes at least 60 million kcal. A gain or loss of 10Kg, representing approximately 90,000 kcal, involves an error of no more than 0.001%.

  • Comprises 2 syndromes:

    • Obesity Hypoventilation Syndrome

    • Obstructive Sleep Apneoa

    • They often occur together – some degree of overlap but 2 distinct conditions


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Obesity Hypoventilation Syndrome during a lifetime, the average person consumes at least 60 million kcal. A gain or loss of 10Kg, representing approximately 90,000 kcal, involves an error of no more than 0.001%.

  • Restrictive ventilatory failure

  • Characterised by daytime hypoxia due to alveolar hypoventilation – reduced ventilatory excursion in the presence of increased requirement

  • Progresses to respiratory failure and right heart failure

  • Diagnosed by arterial blood gas measurement PaO2< or = 7.3 kPa (55 mmHg)