BariatricsBariatrics:: TheThe NextNext FiveFive YearsYears

Kent C. Sasse, M.D., MPH, F.A.C.S, Medical Director Western Bariatric Institute

Founder, International Metabolic Institute Reno, NV AA RevolutionRevolution InIn TheThe MakingMaking

Author:Author: TheThe SasseSasse GuideGuide ToTo OutpatientOutpatient WeightWeight LossLoss SurgerySurgery

•• www.SasseGuide.comwww.SasseGuide.com •• BooksBooks availableavailable onon www.www. Amazon.comAmazon.com andand everywhere.everywhere. WhatWhat IsIs Dr.Dr. SasseSasse GoingGoing ToTo Say?Say?

•• AnAn EpidemicEpidemic ofof ObesityObesity isis HereHere •• AA WeightWeight LossLoss RevolutionRevolution HasHas ArrivedArrived •• OutpatientOutpatient WeightWeight--LossLoss SurgerySurgery IsIs TheThe FutureFuture •• YouYou HoldHold thethe KeysKeys to:to: –– BetterBetter PatientPatient OutcomesOutcomes –– EffectiveEffective CommunityCommunity ServiceService –– BuildingBuilding aa LargerLarger ClientClient basebase –– GreatGreat ASCASC ProfitsProfits WhatWhat IsIs Dr.Dr. SasseSasse GoingGoing ToTo Say?Say?

•• WhoWho willwill bebe havinghaving WeightWeight--lossloss surgery?surgery? •• DoesDoes itit work?work? •• WhatWhat AreAre TheThe RisksRisks andand Rewards?Rewards? •• WhatWhat AreAre thethe KeysKeys toto Success?Success? •• WhatWhat WillWill TheThe NextNext FiveFive YearsYears Bring?Bring? TheThe ObesityObesity EpidemicEpidemic isis HereHere

•• 60%60% ofof AmericansAmericans areare overweightoverweight •• 2020--3030 millionmillion AmericansAmericans areare morbidlymorbidly obeseobese •• ASCsASCs positionedpositioned toto dominatedominate weightweight--lossloss surgerysurgery inin thethe futurefuture •• ObeseObese patientspatients needneed manymany surgicalsurgical servicesservices •• 7070 millionmillion AmericansAmericans havehave ““prepre--diabetesdiabetes”” MorbidMorbid :Obesity: AA MajorMajor HealthHealth ProblemProblem

•• DiabetesDiabetes MellitusMellitus •• HypertensionHypertension •• GERDGERD •• UrinaryUrinary IncontinenceIncontinence •• PickwickianPickwickian RespiratoryRespiratory SyndromeSyndrome •• ObstructiveObstructive SleepSleep ApneaApnea 19851985 Obesity*Obesity* TrendsTrends AmongAmong U.S.U.S. AdultsAdults *BMI > 30 or ~ 30 lbs for 5’4” person

No Data <10% 10%–14%

Source: BRFSS, CDC 19911991 Obesity*Obesity* TrendsTrends AmongAmong U.S.U.S. AdultsAdults *BMI > 30 or ~ 30 lbs overweightoverweight forfor 55’4” person

No Data <10% 10%–14% 15%–19%

Source: BRFSS, CDC 19931993 Obesity*Obesity* TrendsTrends AmongAmong U.S.U.S. AdultsAdults *BMI > 30 or ~ 30 lbs overweight for 5’4” person

No Data <10% 10%–14% 15%–19%

Source: BRFSS, CDC 19961996 Obesity*Obesity* TrendsTrends AmongAmong U.S.U.S. AdultsAdults *BMI > 30 or ~ 30 lbs overweightoverweight forfor 55’4” person

No Data <10% 10%–14% 15%–19%

Source: BRFSS, CDC 19991999 Obesity*Obesity* TrendsTrends AmongAmong U.S.U.S. AdultsAdults *BMI > 30 or ~ 30 lbs overweight for 5’4” person

No Data <10% 10%–14% 15%–19% ≥20

Source: BRFSS, CDC 20022002 Obesity*Obesity* TrendsTrends AmongAmong U.S.U.S. AdultsAdults *BMI > 30 or ~ 30 lbs overweight for 5’4” person

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Source: BRFSS, CDC 20042004 Obesity*Obesity* TrendsTrends AmongAmong U.S.U.S. AdultsAdults *BMI > 30 or ~ 30 lbs overweightoverweight forfor 55’4” person

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Source: BRFSS, CDC ObesityObesity TrendsTrends AmongAmong U.S.U.S. AdultsAdults 20062006

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

14 ObesityObesity TrendsTrends AmongAmong U.S.U.S. AdultsAdults 20072007

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

15 WhatWhat DefinesDefines Obesity?Obesity?

Doctors usually use (BMI) to determine obesity

BMI 25-29.9 (Overweight) BMI 30-34.9 (Mild to Moderate Obesity) BMI 35-39.9 (Obese) BMI 40 or greater (Severely Obese)

Current NIH, ASMBS, and Medicare criteria: BMI over 35 with comorbid condition ClinicallyClinically SevereSevere ObesityObesity •• AA lifelife--threateningthreatening conditioncondition •• AssociatedAssociated withwith comorbiditiescomorbidities •• ShortensShortens lifelife expectancyexpectancy

““TheThe diseasesdiseases associatedassociated withwith morbidmorbid obesityobesity markedlymarkedly reducereduce thethe oddsodds ofof attainingattaining anan averageaverage lifelife spanspan andand raiseraise annualannual mortalitymortality tenfoldtenfold oror more.more.””

– American College of Surgeons ObesityObesity ComorbiditiesComorbidities

•• HeartHeart DiseaseDisease •• DyslipidemiaDyslipidemia •• TypeType 22 DiabetesDiabetes MellitusMellitus •• GallbladderGallbladder diseasedisease •• HypertensionHypertension •• SleepSleep ApneaApnea •• StrokesStrokes •• AsthmaAsthma •• CertainCertain TypesTypes ofof CancerCancer •• ReducedReduced FertilityFertility –– EndometrialEndometrial •• OsteoarthritisOsteoarthritis –– BreastBreast –– ProstateProstate –– ColonColon FACTFACT

““OnlyOnly oneone inin eleveneleven peoplepeople whowho areare 100lbs100lbs overweightoverweight liveslives toto ageage 65.65.””

New England Journal of KidsKids FaceFace aa NewNew ChallengeChallenge

•• ChildhoodChildhood ObesityObesity •• OneOne--thirdthird ofof kidskids •• ,Diabetes, asthma,asthma, andand depression.depression. •• PoorPoor schoolschool performance.performance. •• LowLow Pay.Pay. AcceleratingAccelerating WorldwideWorldwide ProblemProblem ConclusionConclusion

““OnlyOnly surgerysurgery hashas provenproven effectiveeffective overover thethe longlong termterm forfor mostmost patientspatients withwith clinicallyclinically severesevere obesityobesity”” -1991 National Institutes of Health Consensus Conference Statement

EndorsedEndorsed by:by: • National Institutes of Health (NIH) • American Association (AHA) • American Medical Association (AMA) • National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) • American Association of Family Practitioners (AAFP) 3030--7070 millionmillion PeoplePeople NeedNeed aa Solution.Solution. AA RevolutionaryRevolutionary OneOne MustMust Be:Be: •• EffectiveEffective •• DurableDurable •• MinimallyMinimally InvasiveInvasive •• AffordableAffordable •• LowLow RiskRisk •• DiscreetDiscreet WeightWeight LossLoss Surgery:Surgery: AA NewNew EraEra TheThe RevolutionRevolution HasHas ArrivedArrived

•• WeightWeight LossLoss SurgerySurgery WorksWorks –– MinimallyMinimally InvasiveInvasive –– HighlyHighly EffectiveEffective –– SafeSafe –– LowLow RiskRisk –– OutpatientOutpatient OptionsOptions WeightWeight LossLoss Surgery:Surgery: thethe NewNew StandardStandard AnnualAnnual NumberNumber ofof BariatricBariatric OperationsOperations inin thethe U.S.U.S.

250000

200000

150000

Bariatric Operations 100000

50000

0 2000 2002 2004 2006 2008 What is Gastric Banding?

•• AA formform ofof restrictiverestrictive weigweightht lossloss surgerysurgery (bariatric)(bariatric)

•• SoftSoft siliconesilicone--basedbased polymerpolymer •• #1#1 surgicalsurgical procedureprocedure forfor weightweight lossloss inin EuropeEurope andand AustraliaAustralia TheThe LAPLAP--BANDBAND SystemSystem

 BandBand isis placedplaced aroundaround thethe upperupper partpart ofof thethe stomach.stomach. – A small pouch is created – Causes satiety  LessLess thanthan 11 hourhour spentspent inin surgery.surgery.  SameSame--dayday releaserelease (95%)(95%) oror overnightovernight hospitalhospital stay.stay.  ReturnReturn toto workwork inin lessless thanthan 11 week.week.  EvaluatedEvaluated everyevery 66--88 weeksweeks forfor gradualgradual adjustments.adjustments. LAPLAP--BANDBAND AdjustabilityAdjustability

Unfilled Band Filled Band BodyBody MassMass IndexIndex vsvs TimeTime AfterAfter LAPLAP--BANDBAND PlacementPlacement

45 43 41 ) 2 39 37 35 33 BMI (kg/m 31 29 27 25 0 3 6 9 12 18 24 36 48 60 72 Months After LAP-BAND System Surgery Obesity Surgery, Volume 12, 2002 O’Brien et al WhoWho WillWill BeBe HavingHaving WeightWeight--lossloss SurgerySurgery •• ExpectExpect BMIBMI 3030 toto becomebecome thethe newnew standardstandard –– Many,Many, manymany studiesstudies supportsupport thisthis –– FutureFuture FDAFDA approvalapproval atat BMIBMI 30?30? •• ShiftShift toto preventingpreventing diseasedisease •• MoreMore vanityvanity surgerysurgery

Result: Expand pool to 70+ million Americans eligible, more cash pay outpatient procedures Surgery Makes National Headlines

Posted August 23rd on website Weight-Loss Surgery Cuts Rate August 23, 2007, 8:23 am Posted by Jacob Goldstein Weight-loss surgery cuts the for obese people, according to two studies published in this week’s New England Journal of Medicine. The stomach surgery has clearly been shown as a way to help people lose weight, but the question of whether it extends life had not clearly been answered. The author of an NEJM editorial that accompanied the research told the WSJ that the studies are analogous to “the statin trials that showed the drugs reduced death rates and not just cholesterol” — trials that prompted sales of the drugs to skyrocket. The surgery already has been gaining popularity quickly, and is now being studied as a possible treatment for diabetes. One of the new studies, conducted in Sweden, randomly assigned just over 4,000 people to either surgery or conventional treatment. During a follow-up period of about 11 years, those who received surgery were 29% less likely to die than those who received conventional treatment. The other study did not randomly assign people to one group or another, but compared roughly 8,000 people who had surgery with an identical number of people of similar age, sex, and body-mass index who did not have surgery. During a follow-up period of about seven years, those who had surgery were 40% less likely to die than those who did not. OurOur ExperienceExperience

•• SurgerySurgery CenterCenter ofof RenoReno –– 17,00017,000 squaresquare feetfeet –– 55 O.R.O.R. ss –– 450450 totaltotal casescases perper monthmonth –– 1010--1515 LapLap BandBand casescases perper month,month, 11 RYGBRYGB perper monthmonth •• WesternWestern BariatricBariatric Institute,Institute, aa CenterCenter ofof ExcellenceExcellence •• St.St. MaryMary’’ss RegionalRegional MedicalMedical Center,Center, aa partnerpartner WBI: Gender

100%

80%

60%

40%

20%

0% Femal e Mal e n=3428 WBIWBI PatientPatient WeightWeight LossLoss ResultsResults

Average Weight

350 300 250 200 150 Weight 100 50 0 Pre-Op Post-Op Post-Op Post-Op Post-Op Post-Op Weight weight 1 weight 3 weight 6 weight 12 weight 24 288 lbs n=1928

Source: Western Bariatric Institute gastric bypass and Lap-Band patients through 2006 Average OR Minutes

91.6 mins 88.9 mins

70 mins 100 56.7 mins 80 minutes 60

40

20

0 2003 2004 2005 2006 CoCo--morbiditymorbidity comparisoncomparison inin bariatricbariatric surgerysurgery Wittgrove & Clark

ConditionCondition PrePre--OpOp PostPost--OpOp GERD 269269 44 Hypercholesterol 275275 88 Hypertriglyceride 158158 11 Diabetes 8585 11 Glucose Intolerance 5050 00 Incontinence 201201 66 225225 55 118118 1010 Arthritis (symptomatic) 371371 3636 ChangeChange inin QualityQuality ofof LifeLife

Greatly 58% Improved Improved 37%

No Change 5%

Diminished 0 Life Changing Greatly 0 … Diminished WhatWhat isis TheThe FutureFuture ofof WeightWeight LossLoss Surgery?Surgery?

Laparoscopic Roux-en-Y Gastric Bypass and Adjustable Band

LongLong termterm weightweight lossloss LongLong termterm healthhealth improvementimprovement MetabolicMetabolic complicationscomplications nownow onon thethe radarradar RarerRarer surgicalsurgical complicationscomplications ──mortalitymortality 0.0010.001 -- 0.4%0.4%

Schauer PR Annals of Surgery 2000, 232(4)515. InstrumentationInstrumentation AdvancesAdvances

•• ThreeThree RowRow ArticulatingArticulating GastricGastric StaplerStapler -- EndoEndo GIA*GIA* •• IntracorporealIntracorporeal SuturingSuturing -- EndoStich*EndoStich* •• AtraumaticAtraumatic accessaccess devicesdevices -- Step*Step* TrocarsTrocars NationalNational BariatricBariatric SurgerySurgery TrendsTrends andand ProjectionsProjections -- AA fastfast growinggrowing serviceservice --

400,000 300,000 200,000 100,000 Number of Cases 0 1990 1995 2000 2005 2010 2015

Source: American Society for Bariatric Surgeons (ASBS): Innovations Future Center Database OurOur Story:Story: WesternWestern BariatricBariatric InstituteInstitute •• PastPast •• FutureFuture •• 15%15% growthgrowth raterate •• 750750 cases/yrcases/yr •• 80%80% bypassesbypasses •• 65%65% LapBandsLapBands •• 2%2% cashcash paypay •• 10%10% cashcash paypay •• NoNo InsuranceInsurance forfor •• MoreMore AffordableAffordable ComplicationsComplications •• ComprehensiveComprehensive •• InsuranceInsurance forfor ComplicationsComplications OutpatientOutpatient LapBandLapBand

•• TheThe NewNew StandardStandard •• 6060--80%80% ofof casescases •• 95%95% staystay 44--66 hourshours •• <1<1 weekweek recoveryrecovery OutpatientOutpatient GastricGastric SleeveSleeve

•• AA NewNew OptionOption •• DurabilityDurability beingbeing testedtested •• NoNo anastamosisanastamosis •• rapidrapid recoveryrecovery WhatWhat IsIs GastricGastric Bypass?Bypass?

TheThe GastricGastric BypassBypass procedureprocedure isis designeddesigned toto limitlimit thethe amountamount ofof foodfood eaten.eaten. ThisThis isis donedone by:by:

– Dividing the stomach through the use of staples to create a small pouch. – The pouch is 5-10% of the size of the old stomach, therefore holds less food . OutpatientOutpatient GastricGastric BypassBypass

•• ChallengingChallenging •• HighlyHighly SelectedSelected casescases •• AllAll staystay overnightovernight •• HigherHigher riskrisk ofof complicationscomplications andand admissionadmission WhatWhat aa differencedifference aa yearyear makesmakes…… ResolutionResolution ofof CoCo morbiditiesmorbidities

CoCo morbiditymorbidity %% ImprovedImproved %% ResolvedResolved DiabetesDiabetes 18%18% 82%82% SleepSleep ApneaApnea 19%19% 74%74% GoutGout 14%14% 72%72% GERDGERD 24%24% 72%72% HypertensionHypertension 18%18% 70%70% HyperlipidemiaHyperlipidemia 33%33% 63%63%

Source: Schauer et al, “Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Annals of Surgery, 2000 WhoWho qualifiesqualifies forfor surgery?surgery?

ClassificationClassification BMIBMI

Healthy Weight 18.5 – 24.9 AA BMIBMI ofof 3535 –– 3939 withwith comorbidcomorbid conditioncondition Overweight 25 – 29.9 AA BMIBMI ofof 4040 oror higherhigher Obese Class I 30 – 34.9 alonealone

Obese Class II 35 – 39.9 •• EmergingEmerging Standard:Standard: BMIBMI >30>30 Obese Class III > 40 Trends:Trends: WhyWhy IsIs BariatricBariatric SurgerySurgery Growing?Growing? •• ItIt Works.Works. •• TheThe #1#1 mostmost effectiveeffective interventionintervention forfor obesityobesity •• TheThe #1#1 mostmost effectiveeffective treatmenttreatment forfor diabetesdiabetes •• MinimallyMinimally InvasiveInvasive •• OutpatientOutpatient SurgerySurgery •• HighlyHighly DurableDurable Recent Large Multicenter Study: 89% of patients maintain their weight loss at 10 years follow up. FutureFuture TrendsTrends

•• IncreasedIncreased VolumeVolume ofof OutpatientOutpatient CasesCases –– GreaterGreater demanddemand –– PublicityPublicity –– BMIBMI 3030 –– Diabetes,Diabetes, eveneven nonnon--obeseobese •• IncreasedIncreased CashCash--paypay customerscustomers (ASC(ASC feefee $9500)$9500) •• PricePrice ofof LapLap BandBand toto fall,fall, J&JJ&J bandband arrivedarrived 0808 •• MoreMore InsuranceInsurance hurdleshurdles FutureFuture TrendsTrends

•• PricePrice CompetitionCompetition –– MexicoMexico LapBandsLapBands 7K7K –– HolyHoly Grail:Grail: U.S.U.S. LapBandLapBand 10K10K •• ConcentrateConcentrate experienceexperience withwith bestbest surgeonssurgeons andand practicespractices –– BestBest longlong termterm results=bestresults=best advertisementadvertisement –– FewerFewer complicationscomplications •• WiderWider missionmission toto combatcombat obesityobesity ItIt StartsStarts WithWith AllAll ofof UsUs

Talking to Kids and Parents: Obesity Prevention Foundation WhatWhat ServicesServices areare Needed?Needed?

•• AdvancedAdvanced LaparoscopicLaparoscopic SkillsSkills –– TrainingTraining && FellowshipFellowship –– MedicalMedical DirectorDirector –– ASCsASCs shouldshould onlyonly choosechoose thethe bestbest surgeonssurgeons •• ComprehensiveComprehensive prepre--operativeoperative programprogram •• PostPost OperativeOperative programprogram committedcommitted toto thethe successsuccess ofof theirtheir patientspatients –– BandBand fills,fills, counseling,counseling, supportsupport groupsgroups WhatWhat isis thethe FutureFuture ofof BariatricBariatric Surgery?Surgery? •• MoreMore ComprehensiveComprehensive LongLong termterm approachapproach –– PrePre--OpOp –– PostPost--OpOp –– NonNon--OpOp •• SurgerySurgery ConcentratedConcentrated atat ExcellentExcellent centerscenters •• IntegrationIntegration withwith medicalmedical armarm –– Maintenance,Maintenance, plateaus,plateaus, andand relapsesrelapses –– BandBand AdjustmentsAdjustments –– MetabolicMetabolic andand latelate surgicalsurgical complicationscomplications WBI: Reoperation within 30 days of Surgery 25% % Yearly

20% 23% % Reop

15% 16% % 10% 7% 5% 1% 0% 2002 2003 2004 2005 n=266 n=288 n=256 n=447 Emphasis on Quality WBI: % Readmission within 30 days 7% 6% % Readmission 5% 4% 3% 2% 1% 0% 2002 2003 2004 2005 n=266 n=288 n=256 n=44 7

Emphasis on Quality WhatWhat DidDid WeWe NeedNeed atat WesternWestern BariatricBariatric Institute?Institute? •• BariatricBariatric MedicalMedical ComponentComponent –– PreopPreop ProgramProgram forfor HighHigh RiskRisk PatientsPatients –– WeightWeight LossLoss ProgramProgram forfor NonNon--SurgicalSurgical patientspatients –– PostoperativePostoperative programsprograms forfor plateausplateaus andand relapsesrelapses •• LongLong TermTerm FollowFollow UpUp •• DataData CollectionCollection •• GreatGreat ASCASC PartnerPartner FormationFormation ofof iMetaboliciMetabolic

•• MedicalMedical WeightWeight LossLoss •• MDsMDs •• PhDPhD PsychologistsPsychologists •• HealthHealth CoachesCoaches •• FitnessFitness TrainersTrainers •• DietaryDietary CounselorsCounselors •• ChefChef andand MealsMeals •• AugmentAugment anyany bariatricbariatric practicepractice FormationFormation ofof iMetaboliciMetabolic

•• MedicalMedical SolutionsSolutions forfor anyany bariatricbariatric practicepractice anywhereanywhere •• SeparateSeparate EntityEntity – Cash, vs. insurance •• SeparateSeparate facilityfacility – Warm, less medical •• DevelopDevelop ProgramsPrograms – Marketing – Outreach •• ProductProduct andand FulfillmentFulfillment PrePre--OperativeOperative ProgramProgram

•• AA clearclear patientpatient pathwaypathway toto surgerysurgery && supportivesupportive staffstaff membersmembers •• InsuranceInsurance && AuthorizationsAuthorizations SpecialistsSpecialists •• PatientPatient EducationEducation •• 22--44 weekweek liquidliquid dietdiet recommendationsrecommendations •• AA trendtrend towardtoward 33--66 monthmonth medicallymedically supervisedsupervised WesternWestern BariatricBariatric InstituteInstitute PostPost OperativeOperative ProgramProgram •• FollowFollow upup appointmentsappointments –– 11 week,week, 11 month,month, 33 months,months, everyevery 66 monthsmonths •• NutritionalNutritional SupportSupport –– GroupGroup ClassesClasses –– OneOne onon oneone evaluationsevaluations andand plansplans •• SupportSupport GroupGroup ProgramProgram Practical for •• FitnessFitness ComponentComponent most Surgeons? •• TrackingTracking ofof datadata && outcomesoutcomes IncreasinglyIncreasingly StringentStringent InsuranceInsurance RequirementsRequirements forfor SurgerySurgery •• MustMust meetmeet criteriacriteria andand proveprove medicalmedical necessitynecessity •• LetterLetter ofof supportsupport fromfrom primaryprimary carecare physicianphysician •• H&PH&P andand workwork upup fromfrom surgeonsurgeon •• NutritionalNutritional evaluationevaluation •• PsychologicalPsychological evaluationevaluation •• 55 yearyear dietdiet historyhistory •• MedicallyMedically SupervisedSupervised weightweight lossloss programprogram iMetaboliciMetabolic iMetaboliciMetabolic SpecialSpecial ConsiderationsConsiderations forfor ObesityObesity SurgerySurgery PatientsPatients •• SensitivitySensitivity trainingtraining forfor ASCASC staffstaff –– ““MorbidlyMorbidly ObeseObese”” vs.vs. ““SeriouslySeriously OverweightOverweight””

•• UnderstandingUnderstanding thethe shiftshift inin emphasisemphasis toto customercustomer serviceservice PostPost OperativeOperative ConsiderationsConsiderations

•• VitaminVitamin DeficienciesDeficiencies && MonitoringMonitoring –– B12,B12, Iron,Iron, Calcium,Calcium, VitVit D,D, BB complex,complex, AnemiaAnemia •• AnatomicalAnatomical –– BowelBowel ObstructionsObstructions –– GastricGastric UlcersUlcers (No(No NSAIDS!)NSAIDS!) –– BandBand SlipsSlips oror ErosionsErosions –– PortPort SiteSite FlipsFlips •• InsuranceInsurance PackagePackage forfor Complications:Complications: BLISBLIS FoodFood SolutionsSolutions forfor SurgicalSurgical PatientsPatients

•• PreopPreop liquidliquid mealmeal replacementsreplacements –– BasicBasic 800800 kcalkcal LCDLCD forfor 22--44 weeksweeks •• PostopPostop initialinitial 88 weeksweeks –– MealMeal replacementsreplacements –– LiquidLiquid andand chewablechewable multivitaminsmultivitamins •• PostopPostop LongLong termterm –– SurgerySurgery--friendlyfriendly mealsmeals Introducing our own Chef Dave Fouts Designer of the iMetabolic Meals To Go

Great health begins with great nutrition. Whether you are a post Bariatric Bypass or Lapband patient, an individual on achieving or maintaining a weight loss goal through healthier eating habits, or a nutritionally conscious family on the go; iMeals To Go is a great choice for everyone.

Together with Chef Dave Fouts, iMetabolic has created a menu of nutritious and delicious meals. From free range chicken, to beef tenderloin, to fresh grilled salmon and crisp tender vegetables, each meal has been crafted with the healthiest, balanced ingredients. We take the stress out of making healthy eating decisions! All meals are based on a 1200 calorie a day and extreme care has been given to insure that every meal is moist, tender, and tastes just as good as it looks.

Welcome To The New You! Summary:Summary: HowHow OutpatientOutpatient SurgerySurgery IsIs RevolutionizingRevolutionizing WeightWeight LossLoss •• VotingVoting withwith theirtheir feet,feet, weightweight--lossloss surgerysurgery onon thethe riserise •• Safe,Safe, effective,effective, minimallyminimally invasiveinvasive solutionsolution •• ProcedureProcedure isis effective,effective, durable,durable, andand safesafe •• AtAt ASCsASCs,, procedureprocedure isis affordableaffordable andand discreetdiscreet Summary:Summary: WhatWhat DidDid Dr.Dr. SasseSasse Say?Say?

•• WhoWho IsIs AA CandidateCandidate forfor WeightWeight LossLoss Surgery?Surgery? –– BMIBMI greatergreater thanthan 3030 •• DoesDoes WeightWeight LossLoss SurgerySurgery Work?Work? –– Yes!Yes! HighlyHighly Effective,Effective, durable.durable. •• WhatWhat AreAre RisksRisks AndAnd Rewards?Rewards? –– SurgicalSurgical risks,risks, nutritionalnutritional concernsconcerns vs.vs. lifelife expectancyexpectancy •• TheThe KeysKeys toto WeightWeight LossLoss SuccessSuccess –– ExcellentExcellent surgeonssurgeons andand programs,programs, patientpatient educationeducation BariatricsBariatrics:: TheThe NextNext FiveFive YearsYears

•• HugeHuge increaseincrease inin patients/volumepatients/volume •• ShiftShift toto ASCsASCs •• DominanceDominance ofof LapBandLapBand procedureprocedure •• VanityVanity ProcedureProcedure •• MoreMore cashcash--paypay •• DownwardDownward PricePrice competitioncompetition •• InsuranceInsurance productsproducts neededneeded forfor complicationscomplications MakeMake aa DifferenceDifference……StartStart Today!Today! www.obesitypreventionfoundation.orgwww.obesitypreventionfoundation.org (775)(775) 789789--91989198 ThankThank You!You!

Kent C. Sasse, M.D., MPH, FACS

Author:Author: TheThe SasseSasse GuideGuide ToTo OutpatientOutpatient WeightWeight LossLoss SurgerySurgery

www.SasseGuide.com