$75 Million for Bariatrics in Ontario

Big news for patients with severe obesity in Ontario. As part of a $741 Million announcement for a provincial diabetes strategy, the Ontario Health Minister yesterday announced $75 Million in funding for Bariatric Centres of Excellence.

As outlined in the press release:

"Obesity is one of the main risk factors associated with diabetes. More than 50 per cent of type 2 diabetes cases in Ontario are associated with obesity. The government is improving access to bariatric surgery - a procedure that modifies the gastrointestinal tract to reduce food intake. This $75 million initiative will increase Ontario's capacity for bariatric surgery several-fold within two years and it will continue to increase thereafter. In 2006/07 169 procedures were performed in Ontario and 485 patients were funded for surgery out of country.

Ontario will enhance capacity for bariatric surgery in the province by:

- Providing bariatric education and training to health care providers
- Expanding bariatric surgical capacity
- Establishing pre and post bariatric surgery programs that will be linked to surgical programs"

Clearly, a first sign of relief for Ontarians who have thus far had to travel South of the border or scrape together the money for private bariatric surgery.

What I particularly like about the announcement is the emphasis on training health care providers and making sure both pre- and post-surgical care is in place. As I have blogged before, obesity surgery is not just about surgery. The actual operation is only a small technical piece in a complex life-long management plan.

I am particularly pleased by the announcement, because I believe that my past efforts in Ontario, including lobbying of the Government to provide better bariatric care, may in part have led to this announcement. As some readers may know, not only have I been quite vocal about this, but I was also the Clinical Co-Chair of the Health Technology Utilization Guidelines group that was contracted by the Ontario Health Ministry to prepare recommendations for Bariatric Surgery in Ontario.

We made it clear in this guideline document that bariatric care requires an interdisciplinary team and needs to take a chronic disease management rather than an acute-care approach to dealing with this issue.

Given that there is nothing different in the magnitude of the problem or the desperate need for bariatric care between Ontario and other regions of Canada, I can only hope that this announcement will be rapidly followed by similar announcements from other provinces.

Here in Alberta, we certainly have many of the components already in place (at least in the Edmonton Region) - and of course we'd be more than happy to share our experience with our colleagues in Ontario - the sooner we can get the services in place across all of Canada, the better for everyone.

AMS
Edmonton, Alberta

Metabolic Surgery

This week we were reminded that almost 1 in 5 Canadian adults are obese. Readers of my blog will know why this is a challenge - once established, obesity becomes a chronic disease that requires lifelong management (irrespective of whether behavioural, medical or surgical - in all cases treatment is long-term or rezidivism is guaranteed!).

Clearly, for folks with severe obesity, surgery provides the best long-term results. Not only does it reduce mortality by 30-40%, it also leads to marked improvement in virtually all comorbidities while spectacularly improving quality of life.

That is, of course, when all goes well.

But even the safest surgery can result in problems when things go wrong. Recognizing and dealing with complications of obesity surgery is therefore a huge part of the program here at the 25th Annual Meeting of the American Society for Metabolic and Bariatric Surgery that I am currently attending at the Gaylord National on the Potomac River, on the outskirts of Washington D.C.

(My plenary "Keynote Lecture" on Friday morning is on the regulation of hunger and appetite)

No question, world wide obesity surgery is booming. As its value for severe obesity is now well beyond dispute, surgeons are turning to patients with ever lower BMIs - in some cases even below 30. The indication here is no longer weight loss, but rather type 2 diabetes, hence the term "metabolic surgery". Indeed, from everything I have seen and heard, surgery is probably the only known treatment for type 2 diabetes to result in extended remission - in short: highly effective, reasonably safe, and, given the high cost of diabetes complications, certainly cost-effective.

Obviously, the same contraindications apply to metabolic surgery as to obesity surgery, and yes, all patients need lifelong follow up to prevent nutritional deficiencies and ensure persistance with behavioural change (without which surgery does not work). And yes, surgery even at lower BMI's has complications (after all it is still surgery).

As evidenced by the many presentations here, the major determinants of complications are improper patients selection and preparation, low surgical volumes and lack of follow up. A clear warning to any policy makers and payers anxious to increase surgical volumes by simply throwing money at surgeons without providing resources to ensure competent lifelong follow-up.

As blogged previously, obesity surgery is not just about surgery - the actual surgery is simply a small (but important) technical part of a lifelong treatment plan.

AMS
National Harbor, Maryland

Does Presurgical Weight Loss Predict Outcomes?

Contrary to popular belief, patients who undergo obesity surgery do indeed have to make substantial lifestyle changes to be successful - obesity surgery is therefore never a "quick fix".

Therefore, many bariatric programs, including ours, often use modest presurgical weight loss as a screening tool to determine whether patients can indeed make lifestyle changes that would help them be successful after obesity surgery.

The theory is that if someone is unable to make even modest changes to their lifestyles before surgery, they will have difficulty making those changes after surgery, thereby limiting their chances for success.

But does presurgical weight loss truly predict outcomes?

This question was examined by Bushr Mrad and colleagues who performed a retrospective chart review of 562 patients who underwent surgery in our program. The results of this study were just published in the American Journal of Surgery.

One hundred forty-six patients met the inclusion criteria (23 men and 123 women). The mean age was 39.5 years, and the mean body mass index (BMI) was 52.6 kg/m(2). Comorbid disease includes diabetes (15.7%), hypertension (30.8%), mental illness (38.4%), and musculoskeletal disease (56.8%). Procedures performed were 16 vertical band gastroplasties, 43 open gastric bypasses, 52 laparoscopic gastric bypasses, and 35 laparoscopic adjustable gastric bands.

Preoperative weight change was as follows: 31 patients gained weight (21.2%), 56 patients lost weight (38.3%), and 59 patients maintained their weight (40.4%).

While in women, there was no relationship between pre- and postoperative weight loss, men who gained weight preoperatively had significantly worse outcomes.

This study shows that while in women, ability to achieve a modest presurgical weight loss may not matter, in men inability to lose weight may predict poorer success.

Obviously, this study has methodological limitations and only included 23 men - perhaps not enough to make ruling statements about how men do with surgery.

Nevertheless, for now, our program continues to expect patients to demonstrate compliance with lifestyle changes including self-monitoring before considering anyone for bariatric surgery.

AMS
Edmonton, Alberta

IFSO Guidelines for Bariatric Centres

The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), at its Council Meeting in Porto, Portugal, September 2007, approved new guidelines for Bariatric Surgical Centres.

This not only reflects the global interest in this rapidly growing field of bariatric care, but also the need for guidelines that ensure at least a minimum standard of care for patients undergoing surgery for severe obesity.

The summary document, authored by John Melissas, IFSO President (2006-2007) and Head of the Bariatric Unit, at the University Hospital Heraklion, Greece, appears in this month's issue of OBESITY SURGERY.

While most of the recommendations make good sense - this document, not surprisingly, provides a view from the surgical perspective rather than providing a framework for overall bariatric care. There is no doubt that currently the surgeons have the upper hand in this discussion, given that the data increasingly supports the role of surgery as the most effective (if not only) treatment for severe obesity.

However, as I have blogged before, obesity surgery is not just about surgery!

The following are my comments on some of the IFSO recommendations:

"Ensure that individuals who provide services in the bariatric surgery program are adequately qualified to provide such services."

Fully agree, and would probably extend this recommendation to ANYONE dealing with bariatric patients - surgery or no surgery.

"Provide ancillary services such as specialized nursing care, dietary instruction, counseling, and psychological assistance if and when needed."

Another "no-brainer" - again, not only should these ancillary services be available, but health providers in these services should all have undergone basic training in bariatric care including sensitivity training and have at least a basic understanding of the nature of severe obesity, its complications and treatment.

"Have readily available consultants in cardiology, pulmonology, psychiatry, and rehabilitation with previous experience in treating bariatric surgery patients."

I would add to the list general internists, endocrinologists, gastroenterologists, intensivists, hospitalists, pharmacists and perhaps a few other specialities.

"Ensure that basic equipment necessary for the obese patients such as scales, operating room tables, instruments, and supplies specifically designed for bariatric laparoscopic and open surgery, laparoscopic towers, wheelchairs, various other articles of furniture, and lifts that can accommodate stretchers are available, as well as a recovery room capable of providing critical care to morbidly obese patients and an intensive care unit with similar capacity."

This should be an essential requirement for ANY hospital regularly admitting severely obese patients - unfortunately, this is now the case in virtually every hospital in the Western World.

"Have the complete line of necessary equipment, instruments, items of furniture, wheel chairs, operating room tables, beds, radiology facilities such as CT scan and other facilities specially designed and suitable for morbidly and super obese patients."

Same as above - should probably have such lists available in every hospital or medical facility in Canada.

"Have experienced interventional radiologists available to take over the non- surgical management of possible anastomotic leaks and strictures."

Good one! Sometimes these would be interventional gastroenterologists. As often some of these services can be urgently needed, it may not be enough to train only one individual to deal with these issues (travel, vacation, etc.). Obviously, radiology facilities for bariatric patients would be essential (see above).

"Has supervised support groups for bariatric patients."

I agree, support groups can be most helpful for these patients - but they do need supervision to not take off on "tangents".

"Provides lifetime follow-up for the majority and not less than 75% of all bariatric surgical patients."

Obviously, patients with bariatric surgery require life-long follow up - I only do not think that this is best done by the surgeon or "surgical" centres - in fact issues in follow-up are rarely surgical.

They are more often related to nutrition, rehabilitation and psychosocial issues that can ultimately determine outcome. Ideally counseling for these problems would be provided by primary care providers, who are adequately trained in looking after these patients - it is after all not "rocket science" - the majority of patients (if correctly selected prior to surgery) will probably do well with nutritional monitoring, regular lab work and access to psychosocial services as the need arises - all the job of primary care, not that of a surgeon.

Overall the IFSO recommendations are sensible and will hopefully be adopted by policy makers and health authorities in most countries, including Canada. Personally though, I prefer the route taken by the Canadian Association of Bariatric Physicians and Surgeons (CABPS), which ensures that ALL treatment options, both surgical and non-surgical find their place in the management of these complex patients - it is unlikely that surgeons will always provide the best "non-surgical" advise to their patients.

Obesity is indeed an ideal ground for fostering interprofessional practice.

AMS
Edmonton, Alberta

Does Obesity Surgery Convert "Bingers" to "Grazers"?

Classical Binge Eating Disorder (as defined by DSM-IV) is found in around 20-40% of severely obese patients presenting at bariatric centres (including ours). Numerous studies have shown that patients with BED can achieve significant weight loss, resolution of comorbidities and improvement in quality of life with obesity surgery and therefore should not generally be denied surgery.

Nevertheless, many centres (including ours) are reluctant to operate on patients with active BED fearing poorer outcomes and greater distress. It turns out that we really don't know much about how bariatric surgery affects eating patterns in patients with BED.

This question was now addressed by Susan Colles and colleagues from Monash University in Melbourne in a study published in the March issue of OBESITY. Colles and colleagues planned to study eating behaviours in 180 patients before and 12 months following laparoscopic adjustable gastric banding (LABG). Of these, 6 did not receive surgery, 1 died of a myocardial infarct and 44 (25% of eligible subjects) did not return for the 12-month survey (more on this later).

While only 14% of patients had BED at baseline, 31% were described as "uncontrolled eaters", 40% had night eating syndrome (NES) and 26% were "grazers".

Although all groups, including the "bingers" lost similar amounts of weight and BED reduced to 3% in this group, patients with preoperative BED were most likely to develop uncontrolled eating or grazing. Patients who reported uncontrolled eating or grazing after surgery tended to lose less weight and reported greater psychological distress.

Interestingly, the authors report that the 12-month non-responders were more likely to have had presurgical BED, have lost less weight and attended less clinic appointments. This may be due to patients with these behaviours feeling more ashamed about their "loss of control" and therefore avoiding follow-up visits.

This study highlights the risk of preoperative "bingers" to become "uncontrolled eaters" or "grazers" resulting in psychological distress and poorer weight outcomes. As these patients are more likely to drop out of follow-up they may also be at increased long-term risk of nutritional deficiencies and other long-term complications of bariatric surgery.

In an accompanying paper in the same issue of OBESITY, Colles and colleagues describe how "loss of control" may be at the root of the significant psychological distress of patients with BED resulting in their greater likelihood of seeking out bariatric surgery as a means to control their eating behaviour. This may well in part explain the high prevalence of BED in patients presenting in bariatric clinics.

Clearly, we need to learn more about how to pre-screen patients for potentially poor outcomes and how best to monitor post-surgical patients for the development of aberrant eating behaviours.

Given that BED, once diagnosed, is actually quite responsive to psychological treatments resulting in a remarkably high rate of resolution, I wonder about the rational for operating on patients with active BED - after all weight loss should not be the only parameter by which results of obesity surgery are measured.

AMS
Edmonton, Alberta

Opening Eyes to Obesity Management

Yesterday I had the privilege of speaking to around 400 dietitians (and other health professionals) at Capital Health's 12th Annual Regional Nutrition and Food Services symposium.

After my presentation, many of the attendees came up to personally thank me for such an "eye opening" take on obesity.

This of course is surprising, given that you'd think that, if anyone, dietitians would be the ones with the greatest knowledge and understanding of the issues around obesity management.

So I asked the folks who came up to me about what exactly they found so "eye opening".

The answers were pretty much the issues that I have so often blogged about:

- The problems with clinically defining exactly what obesity is and who really needs treatment (no, BMI is not the best criterium!).

- The fact that obesity is a chronic disease that requires life-long treatment - a condition for which we have no cure (with a few rare exceptions).

- The rather limited long-term success of lifestyle (3-5% sustained weight loss), pharmacological (5-15% sustained weight loss) and even surgical (20-30% sustained weight loss) treatments (and even these results only if you continue the treatments!).

- The fact that while maintaining energy balance appears simple (energy in must equal energy out), energy regulation is highly complex.

- The concept that pharmacotherapy and surgery are not a "substitute" for lifestyle change but in fact only work when patients really do make substantial changes to their lifestyle (click here for a previous entry on this topic).

So, to readers of my blog, nothing really new or enlightening - yet, "eye opening" to many in the audience.

I guess we have a long way to go before all health professionals (especially physcians!) understand these basic concepts of obesity management.

If only I could speak to 400 health professionals everyday!

AMS

Obesity Surgery is not Just About Surgery

With the "sensational" results of obesity surgery being publicized in the media, it is not surprising that expansion of bariatric surgery is receiving increasing support. In every province, health plans are carefully looking at expanding access for their populations.

In light of these development it may be time for a word of caution.

Obesity surgery is not just about surgery. In fact, even the most enterprising bariatric surgeons will readily agree that the actual surgery is just a small (but important) technical piece in the overall treatment plan.

No doubt, good surgical outcomes require well-trained experienced surgical teams but we know that much of the long-term outcome depends on what happens before and after surgery.

Done in the wrong patients with no or little long-term follow up, what could be a life saving operation can become a disaster - and weight regain is perhaps the least that can go wrong. Much more severe and potentially devastating are the nutritional deficiencies and the psychological and social consequences that are not seldom after surgery.

For surgery to produce good long-term results it is absolutely essential that as access to surgery expands, so does the pre-surgical selection and education process as well as the access to life-long post-surgical monitoring.

Expansion of surgical programs does not just need more surgeons and OR time - it needs dietitians, psychologists, physicians, occupational therapists, social workers and other health professionals who are trained and qualified to prepare and follow-up surgical patients.

In the end it will be family doctors who have to look after the 1000s of patients who will be asking for and undergoing surgery. Given the numbers of eligible patients and the geographic distances in Canada, this task of preparing and following patients for life cannot be performed by a handful of Centres of Excellence. This is particularly true for the adjustable gastric band, which while offering a simpler and safer surgical procedure, does require regular and ongoing adjustments to be fully effective.

If we hope to see the spectacular results from the published studies on bariatric surgery replicated in daily practice, we must start bringing primary care providers up to speed on counseling, preparing and following their patients.

Ignoring this task will leave 1000s of Canadians stranded post-surgery with nowhere to go when things go wrong.

Obesity surgery is NOT just about surgery.

AMS

What do Patients Expect of Bariatric Surgery - Too Much or Not Enough?

There is no question that with improved results, patients and physicians are beginning to look at bariatric surgery as a realistic and definitive option for the treatment of morbid obesity.

However, do even well-informed patients have the right expectations? This issue was recently addressed by Andrea Bauchowitz and colleagues from the University of Virginia, who examined weight loss expectations of 217 consecutive preoperative patients.

It turns out that over two-thirds of patients (65%) had misconceptions about the amount of weight they would lose after surgery. On average, patients thought that they would lose around 80% of excess weight, when in fact a good response to surgery is probably anything greater than 50% of excess weight.

Almost one-third of patients did not look at surgery as a tool to help make dietary changes and increase physical activity - rather, they thought that surgery would merely prevent overeating.

There were likewise misconceptions regarding length of hospital stay and the importance of post-surgical depression.

Overall, the results of this study show that many patients have misconceptions about the amount of weight loss they can expect from surgery and do not appreciate the need for lifestyle changes after surgery.

Therefore, implementing a thorough patient education program that fosters adequate knowledge about the nutritional and behavioural aspects of surgery as well as the amount of weight loss to be expected may be an important part of preparing patients for surgery.

A previous paper by Bauchowitz, where she examined how bariatric programs evaluate and interpret the psychosocial situation of patients with regard to surgery is available online (click here for full-text). While this study does not tell us whether centres which demand more of their patients have better outcomes, it does provide a list of common practices and things to think about when preparing patients for surgery.

AMS

Caps off to CABPS

It is now widely agreed that looking after obese patients is far more sophisticated than simply advising patients to "eat less and move more".

In fact, the field of bariatrics is rapidly growing into an entity of its own, not just with regard to bariatric surgery but also with regard to bariatric medicine, bariatric nursing, bariatric psychology, bariatric nutrition and other relevant aspects of bariatric care.

It is therefore with great pleasure that I announce the launch of the Canadian Association of Bariatric Physicians and Surgeon's (CABPS) new website at www.cabps.ca

The mandate of CABPS is:

- To bring together Canadian Physicians and Surgeons with a special interest in Bariatric Medicine and Surgery in order to maintain and improve the standards of Bariatric care in Canada.

- To support both primary and continuing educational programs in Bariatric Medicine and Surgery.

- To advance knowledge in the field of Bariatric Medicine and Surgery.

- To facilitate and promote research in the field of Bariatric Medicine and Surgery.

- To develop policies and new ideas in the areas of clinical care, education, and research in Bariatric Medicine and Surgery.

- To represent the views of the Bariatric Physicians and Surgeons of Canada.

- To facilitate communication between the public, the medical community and the ministries of health at the provincial and federal level so as to promote awareness of the health risks of obesity and severe or morbid obesity, the financial and health burden to the individual and to society, and the efficacy of medical and surgical treatment options.

Membership in this organisation is open to all physicians and surgeons with an interest in bariatric care.

Membership (at reduced cost) is also open to all allied health professionals, residents and trainees working in related areas.

Membership forms can be downloaded from the site.

AMS