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• W2887396663 abstract "Mr. JP is a 30 yr single male on medical disability due to a motor vehicle accident (MVA) in 2004. His past medical history includes sleep apnea, gastroesophageal reflux, and traumatic arthritis secondary to the MVA. His medications (all taken on an as-needed basis) included ranitidine, tramadol, albuterol, and imodium. He presented to the Henry Ford Hospital Bariatric Surgery Center in January 2010 inquiring about weight loss surgery. His height and weight at the time of his initial visit were 183 cm and 339 kg, respectively, placing him in the super super morbidly obese category with a body mass index (BMI) of 101.2 kg·m−2 (11).Mr. JP reported being overweight all his life. His high school weight was 136 kg. The highest weight he could recall before his surgical consult was 237 kg, indicating he no longer tracked his weight. He had failed many previous weight loss attempts. In 2001 and 2003, he lost 36 and 41 kg, respectively, with Weight Watchers, but he regained the weight each time. More recently, his physician prescribed the weight loss medication sibutramine, with no effect.Due to his excessive weight, Mr. JP had difficulty ambulating. He spent only two hours per day out of his bed. He was dependent on his parents to help with shopping, meals, and laundry. Additionally, due to his size, he was unable to fit in his pickup truck and thus required transportation in his parents' van. Once a week, he would leave the house to visit a local video store. He described these trips as an “extremely exhausting” experience that resulted in dyspnea and severe knee and low back pain when walking in and out of the store. Additionally, he reported poor sleep quality, with 3 to 4 h per night of inconsistent sleep, often gasping for air when he awoke.His motivation for losing weight included 1) an improved quality of life, 2) to become self-sufficient, and 3) to be able to travel. He also stated that he was fearful he would not live past age 40 unless he lost weight.The surgeon who met with Mr. JP spoke to him about performing a two-staged surgical procedure (see treatment section). Prior to surgery, he was recommended to see a registered dietician and clinical exercise physiologist, which was standard protocol. Additionally he was required to lose >45.5 kg before re-evaluation for surgery.An in-home nutrition and exercise consultation was performed on March 5, 2010, by a registered dietitian and clinical exercise physiologist. It was recommended that Mr. JP begin an 800–1000 kcal per day complete meal replacement plan consisting of 8 high-quality protein, low-fat supplements (Robard Corp., Mount Laurel, NJ), 64 oz of noncaloric fluid intake, and 4 nonstarchy vegetable servings per day. Additionally, he took a chewable multivitamin/mineral supplement with 18 mg iron daily and 1000 mg of calcium citrate. He was also provided a structured progressive exercise program consisting of non-weight-bearing aerobic exercise, resistance training, and increased daily physical activity goals (see exercise training section).He began the meal plan immediately, averaging 894 kcals per day over the first week, with approximately 125–145 g of protein, 15 g of fat, and 50–70 g of carbohydrates. He tolerated the complete meal replacement plan very well, complaining only of constipation and hunger, which subsided after the first few days. For the constipation, he was encouraged to increase his fluid intake beyond 64 oz as well as incorporate the recommended 4 daily nonstarchy vegetables, which provided bulk in the form of fiber.Follow-up consisted of weekly telephone conversations and a secure patient website (BetterMD.net, Janesville, WI) where Mr. JP recorded detailed food and exercise information. He did not have a scale at home to weigh; therefore, he received permission to use a scale at a local medical clinic every other week. To ensure safety, he also scheduled follow-up appointments with his primary care physician. These visits included blood lab assessments to determine electrolytes levels as well as indicators of renal and liver function.Over the initial three months, Mr. JP lost an average of 3.3 kg per week. His initial weight loss over the first month was at 3.6 kg per week. This gradually decreased to 3.2 kg and 2.9 kg per week, respectively, the following two months. His total weight loss over the first six months was 94.4 kg (35.5% of excess weight loss [EWL]). Weight loss progression is captured in Table 1. For a detailed explanation of percent excess weight, see Deitel and colleagues (4).Mr. JP continued to adhere to the meal plan and exercise program throughout the year and was able to slowly progress his exercise to include more walking as tolerated by his knee pain. By September 2010, he reported many benefits from his massive weight loss. His low back pain and dyspnea sensations were much improved, and he was also able to fit in his truck and drive. During his weekly visits to the video store, Mr. JP remarked how he was able to walk through all the aisles without issue. Additionally, he reported spending more time outside his house and that his quality of sleep was much better, as he was now getting an additional 6 h of sleep each night. Due to this success, he decided to postpone his follow-up visit with the bariatric surgeon and continue with his meal plan and exercise program.Despite excellent program adherence and results, by early 2011 Mr. JP became increasingly concerned with his weight loss, which had “slowed” to 1.7 kg per week. He also began experiencing upper-right quadrant pain consistent with biliary colic, which was confirmed with an ultrasound. On February 25, 2011, Mr. JP returned to the surgeon for re-evaluation after losing a total of 138 kg (51.9% EWL). A year after beginning his aggressive weight loss program, Mr. JP safely underwent laparoscopic Roux-en-Y gastric bypass.His postsurgical period was uneventful. Immediately following surgery, Mr. JP was placed on a standard postbariatric diet and continued to progress his exercise duration and intensity. By 6 mo following surgery, Mr. JP lost an additional 33.4 kg, bringing his total weight loss to 170 kg (EWL 64.4%). This was exactly 50% of his initial weight. At this point, his BMI was 49 kg·m−2, which was also approximately half the initial value. See patient photo history in Figure 1.The prevalence of obesity in the United States is well documented, with more than 33% of Americans categorized as obese (6). What is less well defined is the prevalence of those individuals at the extreme end of the obesity spectrum. Data from the National Health and Nutrition Examination Survey (NHANES) suggests that 5.7% of the population falls into the extreme obesity category (i.e., BMI >40 kg·m−2), up from 2.9% in 1994 (6). However, as the average BMI of patients undergoing weight loss surgery is 50 kg·m−2, the NHANES data provides limited information because it does not allow for comparisons at higher BMI categories. The American Society for Metabolic and Bariatric Surgery (ASMBS) provides two additional BMI categories at 50 kg·m−2 (super obese) and >60 kg·m−2 (super super obese) (11). Approximately 200,000 bariatric surgeries were performed across the United States in 2010, with 6% of the cases in the super super obese category.Medical conditions (e.g., Prader-Willi syndrome, hypogonadism, polycystic ovarian syndrome, hypothyroidsm, etc.) account for less than 1% of the obesity cases (15). Constant access to high-caloric foods as well as reduced levels of physical activity largely explains the majority of the world-wide obesity epidemic. However, the antecedents that lead an individual to become super obese likely involve additional factors beyond an obesogenic environment. Children who have obese parents are twice as likely to become obese as adults, suggesting a genetic component. Additional correlates found in this population are an existing disability as well as a history of childhood maltreatment (9,16). Williamson and colleagues reported physical, sexual, or emotional abuse during childhood to be more likely reported in individuals with a BMI above 40 kg·m−2 compared to individuals with a BMI between 30 and 40 kg·m−2 (1,17).The diagnosis of obesity or super obesity is made simply by taking a standard height and weight to calculate BMI. The onset of obesity can occur at any time in a person's life; however, an overweight child (i.e., 2- to 17-years-old) has greater than a 75% likelihood of becoming an obese adult, while a normal weight child has only a 7% chance of obesity.A retrospective, case-control analysis of 9,949 patients who underwent gastric bypass surgery revealed an all-cause mortality benefit for those receiving bariatric surgery (1). This 7-year study also showed the survival difference to be greater when comparing surgery versus nonsurgery individuals at the high ends of BMI (i.e., BMI >45 kg·m−2). However, many individuals in the super super obese category have suboptimal weight loss outcomes following bariatric surgery compared to their lower BMI counterparts (5,7,10,13). Furthermore, individuals in the super super obese category require greater operating room times, spend more days in the hospital following surgery, and are likely to be discharged to chronic health care facilities (13). Finally, because of technical difficulties during gastric bypass surgery (e.g., laparoscopic instruments cannot easily reach, body wall mechanics, etc.), a greater number of comorbidities, and a greater perceived surgical risk, the super super obese individual is sometimes considered inoperable by bariatric surgeons (7,12,18).To improve outcomes and reduce risk in the super super obese, some surgeons will perform a two-staged procedure, typically involving two separate operations. The first surgery is a vertical sleeve gastrectomy where 80% of the stomach is removed, leaving a long, narrow tube of stomach based along the lesser curve. At a later time, once weight loss has plateaued, the sleeve gastrectomy is converted to a gastric bypass or duodenal switch. This is all performed by using laparoscopic surgical techniques. This approach was presented as a way to decrease the surgical morbidity and mortality when operating on the super obese. Interestingly, Dillemans and colleagues reported no consensus opinion regarding the best surgical procedure (or procedures) for weight loss in the super super morbidly obese (5).Regarding the use of very low calorie diets to augment weight loss, very little has been reported in this BMI category (3,8,14).During the initial visit with Mr. JP, it was clear he would not tolerate most standardized exercise tests. He was visibly uncomfortable and exhibited exertion-related dyspnea symptoms from the effort of sitting upright for 30 min. His resting heart rate was 96 beats·min−1 with an oxygen saturation of 93%. A blood pressure was attempted by using a thigh cuff, but due to his large arm circumference, it was technically impossible to obtain (see Table 2).After standing for 3 to 5 min, he needed to sit and rest and complained of lower back pain. Therefore, in lieu of the 6 min walk test, he performed a modified version of the “timed up and go” test as well as a timed chair stand test. For the modified “timed up and go” test, Mr. JP began in a seated position in the kitchen, stood and walked to the living room front door, and then returned to the kitchen chair. The distance covered was 4.6 m in 27 s. Upon completion, his heart rate increased to 120 beats·min−1 and his oxygen saturation dropped to 89%. A similar drop in oxygen saturation was observed (89%) during the 30 s chair stand test, where Mr. JP was able to perform 12 repetitions of standing from a seated position without arm assistance.At his 6 mo follow-up visit (95 kg weight loss), Mr. JP had a lower resting heart rate (80 beats·min−1) and normal oxygen saturation (95%). He displayed functional improvements with both tests, completing the modified “timed up and go” test within 19 s and performing 15 repetitions during the 30 s chair stand test. Additionally, his oxygen saturation during these tests was unchanged from rest, remaining at approximately 95%. This was despite higher heart rate responses of 129 and 132 beats·min−1, respectively.A 1 yr follow-up assessment was conducted at the William Clay Ford Center for Athletic Medicine in Detroit. Due to his improved mobility and weight loss of 138 kg (BMI 60 = kg·m−2), his functional capacity was measured by using the standard 6 min walk test as outlined by the American Thoracic Society (2). During the test, he was able to walk the entire 6 min period without rest, covering 373 m. His heart rate rose from 76 beats·min−1 at rest to 125 beats·min−1 at test completion. His oxygen saturation remained unchanged from rest (95%).At his most recent visit, at 6 mo following gastric bypass surgery and 18 mo after the initial home visit, Mr. JP again performed the 6 min walk and improved the distance by 33% (498 m). Additionally, his heart rate increased from 64 beats·min−1 at rest to 100 beats·min−1 at the end of the walk indicating improved cardiovascular endurance.Mr. JP had several barriers to exercise, including severe pain in his lower back and knees, shortness of breath with minimal exertion, lack of appropriate exercise equipment, lack of exercise facility near his house, and lack of financial means to purchase exercise equipment. Due to these constraints, a recommendation of using primarily non-weight-bearing exercises (e.g., chair aerobics for 10–15 min per day) was made. Exercise intensity was self-regulated to range between an 11 and a 13 on the Borg perceived exertion scale (“fairly light” to “somewhat hard”). In addition, he was encouraged to sit in an upright chair for 2 h each day, stand several times per day for >5 min at a time, and begin walking as tolerated around his house.Shortly after the first week of exercise, he discontinued his walking until he received clearance from his primary care physician. This was due to a reported “slipping” knee cap sensation while walking. While no structural damage to his knee was identified, the severity of his knee pain would fluctuate throughout the follow-up period. He altered his exercise plan based on his pain tolerance. He was eventually able to increase his outside walking distance over the first 3 mo from one house to one-half block. Additionally, he improved his time performing daily chair aerobics from 10 to 15 min.As his weight loss progressed, his exercise tolerance increased. At 6 mo, in addition to his daily chair exercises, he was walking daily for 20 min and could complete a block around his neighborhood. By 1 yr, his walking times progressed further, averaging 40 consecutive minutes or more each day.Following surgery, he continued walking for the first 3 mo before enrolling in an exercise program offered through Henry Ford Hospital. He was very adherent to the program, averaging >3 visits per week (perfect attendance = 4 times per week). Initially, he performed aerobic exercises for 65 min before progressing to 110 min. He primarily performed three exercise modalities (treadmill, recumbent stepper, and swimming pool activities). Most notably, on the treadmill, he improved his time and speed from 30 min at 2.5 mph (heart rate 130 beats·min−1) to 60 min at 3.2 mph (heart rate 123 beats·min−1). After 2 mo in the Henry Ford Hospital program, he joined a health club closer to his home, where he continues to exercise 4–5 d·wk−1.Due to severe functional limitations and multiple obesity-related health conditions, individuals at the extreme upper BMI values are more likely to be medically disabled and are at very high risk of significant morbidities and mortality. Unfortunately, many of these individuals do not respond well to weight loss attempts, even after bariatric surgery. This case study is an example of how a combined multidisciplinary team using dietary, exercise, and surgical approaches to weight management can produce excellent and safe results. While little research on this topic exists, Huerta and colleagues demonstrated the feasibility of inducing a >10-point drop in BMI in a cohort of 5 super morbidly obese individuals (BMI = 64.3 + 2.1 kg·m−2) (8). Furthermore, the drop in BMI was accompanied by a concurrent improvement in cardiovascular risk factors (e.g., glycolated hemoglobin). This may be a future model for other cases like Mr. JP's, but further research is needed to determine if aggressive presurgical weight loss of this magnitude can assist in patient outcomes during and after bariatric surgery." @default.
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• W2887396663 date "2012-03-01" @default.
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• W2887396663 title "A Trans-Disciplinary Approach to Weight Loss in the Super Super Morbidly Obese" @default.
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