Nationaal Preventie Akkoord

Transcriptie

1 Nationaal Preventie Akkoord

2 Nationaal Preventie Akkoord Doelstellingen in 2040: Overgewicht bij jeugdigen van 13,5 -> 9,1% Overgewicht volwassenen van 48,7 -> 38% Obesitas volwassenen van 14,5 -> 7,1% Evenredige daling van aantal Nederlanders met comorbiditeit van obesitas.

3 Maar..

4 De cardiovasculaire zorg(en) van morgen Frits Berends, chirurg

5 Disclosure

6 WOENSDAG 17 OKTOBER 2018

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8 Wilskracht : Nu lijkt dikte mij geen ziekte, maar eerder het gevolg van onmatigheid en een gebrek aan zelfbeheersing en wilskracht 8

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10 9 JUNI

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12 Bariatrische chirurgie: Cracking nuts with a sledgehammer?

13 Obesity in the Netherlands (BMI > 30) BMI>25 50% BMI>30 15%

14 Projected rates of obesity

15 Is this the new normal?

16 Obesity comes with a price Higher leave of abcense More disability More unemployment More depression More comorbidity Lower life expectancy

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18 OBESITY

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21 Lifetime risk of developing T2DM at Age 18

22 Obesity and risk of developing heart disease

23 YEARS LOST BMI and Life Expectancy >45 BMI 20 years old 30 years old 40 years old 50 years old Fontaine et al. Jama 2003

24 Richtlijnen in NL 2006 NICE: the prevention, identification, assessment and management of overweight and obesity in adults and children 2008 CBO: Diagnostiek en behandeling van obesitas bij volwassenen en kinderen 2010 PON: Zorgstandaard Obesitas 2011 NVvH: Richtlijn morbide obesitas

25 Niveau preventie GGR GGR Behandeling

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27 The energy balance Weight gain Weight loss ENERGY IN (Calories) ENERGY OUT (activity)

28 The obese patient Weight gain ENERGY IN (Calories) ENERGY OUT (activity)

29 ETHNICITY HORMONAL SLEEP STRESS MEDICATION ENVIRONMENT MICROBIOOM GENETICS EATING HABITS

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31 1. More hunger 2. Less satiety 3. Metabolism slows down

32 The Setpoint

33 GEWICHT TOENAME DIEET/ SPORT > HONGER < VERZADIGING < STOFWISSELING SYSTEEM VERDEDIGD SETPOINT

34 GLI! Does it work? Literatuur: in de beste studies 5% gewichtsverlies Na 2 jaar Goal: >15% gewichtsverlies Meer dan 3 jaar

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36 Bariatric surgery in the Netherlands: 17 million people operations/yr About 20 centers Reimburst surgery No private care

37 Maagverkleining criteria NIH 1991 BMI > 40 - T2DM Gastrointestinal surgery for severe obesity: National Institutes of Health Consensus Development Conference statement. Am J Clin Nutr 1992;55:615S 619SS. [ BMI > 35 met comorbiditeit - HT - OSAS - Gewrichtspijn

38 Welke operaties Sleeve gastrectomy Gastric bypass

39 How does surgery improve diabetes?

40 How does surgery improve diabetes?

41 Mean Percent Weight Change during a 15-Year Period in the Control Group and the Surgery Group Sjöström et al. N Engl J Med. 2007

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43 Clinical Benefits of surgical treatment of diabetes Durable Remission of Hyperglycemia in at least 50% of surgically treated pts Mingrone G Rubino F. Lancet 2015

44 Diabetes Control in pts with BMI < 35Kg/m2 STAMPEDE Trial Medical BMI 35 vs<35 Surgical BMI 35 vs<35 Value at Visit Medical <35 BMI 9.1 (8.9) 7.2 (6.8) 7.9 (6.9) 8.8 (7.4) 8.1 (7.8) Medical35 BMI 8.8 (8.5) 7.1 (6.8) 7.2 (6.7) 7.4 (6.9) 8.5 (7.3) Medical <35 BMI 9.4 (9.1) 6.7 (6.9) 6.6 (6.6) 6.8 (6.8) 7.1 (6.7) Medical 35 BMI 9.3 (9.2) 6.4 (6.2) 6.4 (6.1) 6.6 (6.4) 6.7 (6.4)

45 Benefits of surgery go beyond remission Rubino F. Nature 2016

46 Percentage Without Diabetes Longer duration of diabetes at baseline is associated with lower long-term disease remission-term Figure2. Diabetes Remission by Diabetes Duration in thesurgery Group 100 Diabetes duration at baseline <1 y y 4 y Follow-up Time, y Total participants <1 y y y JAMA, June 2014

47 Meta-Analysis of Surgical vs. Medical Treatments for T2DM in BMI <35 HbA1c Lower HbA 1c with surgery despite far fewer diabetes meds compared with non-surg Muller-Stich BP et al, Ann Surg 2015

48 Odds of Diabetes Remission or Glycemic Control in All 11 RCTs of Surgery vs. Meds/Lifestyle Care for T2DM Level 1A Evidence: ] ] Surgical Superiority is Similar in BMI 35 and >35 Medical/Lifestyle Surgery BMI 35 BMI > 35 Ascending Mean Baseline BMI Favors Meds-Lifestyle Favors Surgery

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50 Management of T2DM BMI>40: Direct chirurgie BMI>35: Overweeg chirurgie onafhankelijk van GLI. Geen GLI+ BMI>30: Overweeg chirurgie als GLI onvoldoende

51 Maar hoe zit dat dan bij andere co-morbiditeit? Hypertensie Hypercholesterolaemie Hyperlipidemie Ritmestoornissen Infertiliteit Gewrichtsklachten Slaapapneu Thrombo-embolieen....

52 Be careful what you wish for. 2% Morbide obesitas = ,5% T2DM > % Obesitas > % Hypertensie >

53 Nadelen 2% ernstige complicaties, Mortaliteit 0,2% Levenslang vitamines Dumping Kans op weight regain 25% Overtollige huid operaties niet vergoed Meer verslavingsgedrag na Ok Voldoet niet altijd aan verwachting.

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55 Thank you! Suggestions/ Questions: Frits Berends