 Okay. What is obesity? Obesity is a significant health problem that is affecting all countries with increasing rates. The World Health Organization defines it as an abnormal fat accumulation that presents health risks. It is a chronic disease. How do we measure obesity? There are several ways to measure obesity. The two most commonly used are the BMI, which is what the insurance companies use to allow us to perform surgeries, but another important way to measure it is the waist to hip ratio. The waist to hip ratio essentially measures your waist size at its smallest point divided by your hip size at the largest point, and that ratio should it be greater than one poses a higher risk of cardiovascular disease. So even patients with the same BMI can have a different waist to hip ratio, and those with a higher ratio will tend to have a higher cardiovascular risk. So if you could see our little images there, pear shape actually being healthier because the waist size is smaller, whereas women with larger wastes have a higher risk of cardiovascular disease. So the BMI, that's how we really measure which patients would be candidates for surgery or medical weight loss. The BMI is measured by dividing the weight and kilos by the height. A BMI, as you can see here, is considered overweight for anything over 25, and patients are in the obese category once they're over 30. Morbidly obese is considered a BMI over 35. Obesity is a multifactorial disease, most of which is hard to control. The genetic part of it is out of our control. Even the environmental part of it is out of our control. As you drive around, all you see is McDonald's, Wendy's, Burger King, fast food places, and on TV, you'll have commercials for lots of candy, cookies, tostitos, all these yummy things that are not very healthy. That's a big industry. It's a very profitable industry, so that's not going to change as well. So the only control we have of this multifactorial disease is our behavior. The slide shows over the last several decades what is going on in the U.S. There was not a lot of data back in 1985, but as you could see from 1990 going forward, the percent of patients considered obese in the U.S. has climbed from 1990, where it's about 14 percent or so. Decade, every five to ten years, it's been recalculated and a new color shows up pretty much every ten years as the percent continues to increase. Most recently, last year's data in 2022, two states, Kentucky and West Virginia, have obesity rates in the 45 to 50 percentile range. That is clearly an epidemic. So why do we worry about obesity? Well, we worry about obesity because of the comorbidities that it causes, and it affects essentially all parts of the body. As an obese patient, you're certainly at an increased risk of having strokes. That's a big major comorbidity. Heart and lung disease, patients usually have high blood pressure as well as heart disease. Restrictive pulmonary disease as well as sleep apnea, diabetes, fatty liver, and patients are at risk for a lot of different cancers, most notably for women, breast and ovarian. As well with our younger patients that maybe don't have obesity for very long, their main concerns are usually infertility and PCOS. As they age, then the risk of cancer certainly increases. Let's talk about the cancers associated with obesity. Again, for women, most importantly, ovarian and breast cancer, to minimize the risks, you really have to get the obesity under control. And the reasoning is that obese women have higher estrogen and progesterone levels because the estrogen and progesterone is in the fatty tissue. So as you lose weight, your levels decrease and your risks decrease. How do we treat obesity? Well, it depends upon the level of obesity. If you're just overweight and your BMI is higher than 25, which makes you overweight, but less than anywhere between 27 and 30, then it's all about lifestyle modifications. Good old-fashioned diet and exercise. But as you get higher on the BMI scale, then you become a candidate to do either surgery or medical weight loss. A BMI of over 27 will qualify you for medicines. But you have to have associated comorbidities, specifically high blood pressure, diabetes, or high cholesterol. If the BMI is over 30, you qualify for medicines without needing to have any comorbidities. And that essentially is more common for younger patients that are overweight. So younger patients haven't had obesity long enough sometimes to have high blood pressure or diabetes, so they would be candidates. Once you get a BMI over 35, you become a surgical candidate, specifically if you have comorbidities. And when it comes to surgery, the comorbidities can be high blood pressure, diabetes, they could be osteoarthritis, they could be heartburn, which is gastroesophageal reflux disease. Okay, so this is a slide essentially showing what I've just discussed with your BMI of 27. You have to have some sort of weight-related comorbidity, specifically high blood pressure and diabetes. BMI of over 30 does not require you to have a comorbidity and weight loss, surgical weight loss for those with a BMI of over 35 with a comorbidity or over 40 without comorbidities. So let's start with the medical weight loss, the pharmacological weight loss. Six different drugs have been approved by the U.S. FDA for long-term use specifically. Contrave. Contrave is an oral medication that works on the brain to control cravings. This targets receptors in the brain that tell us we're hungry. Contrave can be taken three times a day with meals, and the goal is to control your eating. In addition to any type of pharmacological medication, clearly diet and exercise has to be part of weight loss. The other oral medication or the stat is a lipase inhibitor that's also an oral medication, and that essentially causes steateria, which is you don't absorb fats, so the fat comes out of the stool. Let's see. The next oral medication, entramine, has been around for a long time. Fentramine is a CNS stimulator. It stimulates the central nervous system and suppresses your appetite. So it's an appetite suppressant also taken orally. Fentramine can cause high blood pressure as it does stimulate the central nervous system, but it does decrease the appetite. The next two that are listed here, wagovi and sexenda, they are both GLP1 agonists. They are taken, their injectables, they are started at a low dose and slowly advanced to a higher dose and they decrease appetite by essentially giving you the feeling of fullness. Because the stomach doesn't empty as quickly. The side effects of wagovi and sexenda can be pancreatitis as well as gobladder symptoms. The last weight loss drug, the incurvi, is really only used selectively for patients that have syndromes such as Bartet-Badel syndrome, which is a genetic abnormality. This drug targets the impaired pathways with that. Okay, let's talk about surgical weight loss. Several options out there for surgical weight loss, gastric band, gastric sleeve and the gastric bypass. The gastric band works by taking the sidelastic tubing, wrapping it around the upper portion of the stomach, creating a little stomach pouch above it. That band is then connected to a tubing to a fill port. That fill port is then secured to the anterior abdominal wall and that is accessed in the physician's office and we tighten the band. So the goal is to find what we call the sweet spot where we tighten the band and it keeps food in that upper stomach pouch long enough that you have several hours of satiety. Again, this is a surgical procedure. It takes about an hour in the operating room and patients return to work pretty quickly. The downside, I guess, being that they do have to come back to the office to see us every two months or so for accessing the port and making the band a little tighter. That's only in the first year or so once we do find that sweet spot patients can spend months to years without eating adjustments. The average weight loss is about 50 pounds in a year. It's about a pound a week with the band. The next procedure is the gastric sleeve. With the gastric sleeve, what we're doing is we're creating a smaller stomach. Again, it takes about an hour in the operating room. The excess portion of the stomach that was divided is removed. The patient has to heal that staple line. So as far as recovery takes a little bit longer to recover, that staple line has to heal. So patients are kept on a liquid diet for the first week, advanced to a full liquid the second week, and then purees for a couple weeks as we're trying to protect that staple line from any leakage. Those patients tend to lose weight much quicker with an average of about 100 pounds over the first year. The nice thing about the sleeve is that not only does it give you restriction because we've taken a lot of the stomach off, but the hunger hormones that were in that excised portion of the stomach, which is all this, patients really do have less hunger if at all, sometimes patients don't have any hunger. And lastly, we have the gastric bypass. The gastric bypass is the most involved out of the three. With the gastric bypass, we make a smaller stomach, which you can see here. So we divide the stomach here and we leave just a small stomach pouch. We then connect that stomach to the small intestines. That small intestine connection, therefore there are two small intestine connections. And what this does, it does do two things as well. You have restriction because there's a small stomach, but as well there's malabsorption because this whole length of small intestine going down until what we call the billar limb connecting the calories aren't absorbed as well. So these patients tend to lose weight even quicker on average about 150 pounds in the first year. So here at Bayshore, we have a comprehensive centre where we offer pharmacologic as well as surgical weight loss. We have a team that includes our nursing staff as well as nutritionists and psychological counsellors. We offer primary surgeries. We offer revisional surgeries. And when patients, should they come back from another surgeon or one of our surgeries and have regained weight? Again, we offer them the pharmacologic or revisional options. Okay, so we'll start with the first question. So the recovery, most patients do feel good after the first week and they're having their liquid diet, their protein shakes and they're back to their energy. However, we don't let them resume full activities for six weeks because with all these procedures, the incisions have to heal. We don't want them to get hernias. So no strenuous activities are lifting for six weeks. On average, patients will return to work between one and two weeks unless they have a very strenuous job and then they do need to stay out for the six weeks. And as far as the results and how patients will expect to do, part of it will depend on if they're following the program. So none of these procedures work if the patients are not ready to make this a full lifestyle change. So we offer them both medicines and or surgery as a tool, but they have to still diet and exercise. It's a part of any weight loss. So if you're keeping with the program and you're following with us and we're keeping you on track, patients do great. And they have basically a lifetime of where they've lost weight and they've lost their comorbidities and they're healthier and they're happier and they will not regain their weight. There certainly are patients who can regain their weight because they fall back to bad habits and those patients we try to get back in and try to help them with, you know, whatever's made them fail. Yeah, they all have potential risks. So the two that we use most frequently the contrary, which is the oral medication, you know, contraindication of that would be if you've had any type of seizure history, because that affects the brain, it works on the receptors in the brain. So, you know, everyone is individual, you have to go through your medicine list and see if that would be a particular drug that you could have and if it's going to work on what your main problem is. So that patient would have to have cravings that need to be controlled. The other medication that we use the Wagovie. Again, it depends on, they can't be on certain diabetic medicines, but again, as on an individual basis, we have to review the medicines that a particular patient takes and see if they're appropriate for that medication. And then it is very well tolerated. The side effect can be a lot if you actually look at the package and serve. However, the most common, even though it's not common would be a pancreatitis or all that. Patients can certainly get nauseous and vomit because it does affect the emptying of the stomach. But that just means you have to eat less frequently because you have to allow the stomach to empty. Patients come in and have a consultation with one of the surgeons in the office and we assess what their issues are and what would be the best management for them. If they truly are morbidly obese and a surgery would be indicated, we discuss several different surgical options and come up with what would be best for them. Once we've discussed that and discussed all the risk benefits, pros, cons, we have them sit with members of our staff and they'll tell them the process which essentially is getting different clearances. The insurance companies have prerequisites that they have to fill. Specifically, everyone will need a psychiatric evaluation and clearance as well as multiple nutrition visits. The nutrition visits will be anywhere from three to six months worth of nutrition. In addition to that, we have patients have GI evaluation. We want them to have an upper endoscopy. We want them to know or we want to know if they have any ulcers in the stomach, any tumors in the stomach, any bacteria that would affect them postoperatively. So everyone gets a preoperative endoscopy to clear them before surgery. In addition to that, they'll either have medical clearance to make sure they're overall good candidate for general anesthesia or if they're older and have any cardiac issues, they may as well get a cardiac clearance as well. So some patients will get cardiac as well as pulmonary clearance if they have any sleep apnea or potentially have sleep apnea if they're snores or if they have any asthmatic issues and we want to make sure that they're adequately clear from the pulmonary standpoint. On average, patients from the time of their consultation will have surgery usually in three months, but they do have a lot of work to do in those three months. We have a nutritionist that's in the office whenever we're in the office, so not only will the surgeon speak to you and discuss where the pitfalls may be, but in addition to that, you could speak to the dietician and she'll give you great advice as to what foods are the best for you and different techniques for you to lose weight. So if a patient already has the subspecialists, they could see their own doctors. So if they have their cardiologist, GI doctors, they'll see their own doctors. If they don't have any of those doctors, we'll give them referrals for those doctors. We'll give them names of docs that we work with and they'll make their own appointments, but we'll follow up with those doctors to get the results to expedite the process of getting through this.