01.06.12
Bariatric surgery
Source: National Health Executive May/June 2012
Dr David Haslam, chair of the National Obesity Forum and a Hertfordshire GP, and its vice-chair Debbie Cook, a clinical nurse manager, discuss the evidence base for bariatric surgery, which could be under threat in the new commissioning landscape.
The commissioning baton being handed over to primary care is a great opportunity for clinicians to wrest control of their patients from pen-pushers, but there is a danger that the state-of-the-art treatment of obesity and type two diabetes with bariatric surgery will fall by the wayside because of lack of knowledge and short-termism.
The current fiscal challenges faced by new commissioners will be overwhelming and the mandate to tighten the purse strings and provide value for money could nudge some to abandon costly bariatric surgical options in favour of the softer cheaper option of diet, intensive lifestyle changes and pharmacotherapy.
They would be wrong.
There is a prevailing feeling that fatness represents gluttony and sloth, easily undone by a modicum of willpower and a pair of decent trainers. Surgery as a means of undoing damage done by indulgence in cream, pies and fizzy drinks, in an economic climate of fiscal constraint, doesn’t sit comfortably with health economists, already forced to ration cancer drugs due to ‘lack of cost effectiveness’. Traditional lifestyle modifications such as diets and exercise are much more morally acceptable (Thoresby 2010), although almost certain to fail in the long term, a fact recognised by NICE, who promote bariatric surgery as first-line treatment in those with a BMI >50 and as an appropriate treatment for those with a BMI as low as 35.
Bariatric surgery includes gastric bypass, sleeve gastrectomy and gastric banding, which to varying degrees cause restriction of food intake and reduced absorption of nutrients, although there appear to be other, as yet unidentified metabolic mechanisms which induce the resolution of diabetes post-gastric bypass within days, or sometimes hours, even before any weight is lost. The Swedish Obese Subjects study and others, some of which have been running for more than twenty years, demonstrate s i g n i f i c a n t sustained weight loss accompanied by reduction in premature mortality especially through cancer and heart attack deaths, and the resolution of c o - m o r b i d i t i e s such as diabetes and sleep apnoea in the majority of individuals. Usually carried out by keyhole surgery, the procedures have a low risk and are well-tolerated.
In the new world of GP commissioning, funding will flow according to the whim of a body of people who have traditionally been reluctant to embrace the concept of primary care responsibility for the burden of obesity care.
Once GPs govern the fiscal flows, they may think differently and seize the opportunity to save lives, and put diabetes into remission in the most hard-to-manage cohort of patients, based on a robust and compelling economic argument, or they might take the easy option of short term savings, and spend the money on glucose-lowering agents, statins and ARBs, most of which could be stopped following successful surgery.
In a persuasive study, Cremieux and colleagues in 2008 estimated that the downstream associated costs of bariatric surgery are estimated to offset the initial costs in a matter of only 2 to 4 years. Costs of surgery are dwarfed compared to medical and surgical bills incurred by cumulative pharmacological, medical and social costs if surgery is denied. There are also the human costs, to the individual, their family and society to consider.
Economic modelling by the National Bariatric Surgery Register suggests that surgery can pay for itself within as little as two years based on clinical costs alone. The Office of Health Economics’ ‘Shedding the Pounds’, looked at wider economic benefits; the contribution of individuals resuming paid work, and stopping benefits following surgery off-sets the costs after a mere one year.
If 5% of eligible patients received surgery, savings at 3 years, not including clinical cost savings, would be £382m. If 25% underwent surgery, the figure would be £1.295bn. The Picot review studied clinical and cost-effectiveness, concluding that bariatric surgery is a more effective intervention for weight loss than nonsurgical options and that although surgery is more costly than non-surgical management, it gives improved outcomes.
For morbid obesity, incremental costeffectiveness ratios ranged between £2,000 and £4,000 per QALY gained; highly cost-effective from an NHS decision-making perspective.
Obesity is multifactorial; poor choice and personal responsibility are only small factors of a widespread problem; society shouldn’t be collectively blamed for its lack of appetite control and inability to exercise (Brownell and others 2010).
In a report by Blakemore and Frogeuel (2009) over 30 genes responsible for fatness have been identified which may contribute to the development of both diabetes and obesity, and the concept of epigenetics is compelling as a factor, although Capehorn (2010) points out that it is not useful to lay the blame for obesity on genetics, as this shifts the blame from personal to ancestral which is unhelpful in developing strategies to address the problem.
We certainly live in an obesogenic environment and numerous studies have shown that the responsible agents include sugar-sweetened beverages, endocrine disruptors and high fructose corn syrup. More effort should certainly be spent on prevention – influencing policy makers to create more green spaces, cheaper food, more cycle paths and flexible working arrangements that help young parents walk their kids to school safely. But surgery is another answer to a changing environment; doing what evolution would do in response if it was quick enough – providing a smaller stomach and a shorter bowel.
There are many ways to combat obesity; improved food labelling, reformulation of nutrients, food taxes (on sugars and carbohydrates, not fat!) improved cooking skills in schools and in the work place, calorie labelling on menus…
Food and drink intake is not the only threat to health; evidence is clear regarding the role of activity; groups such as Sustrans, Green Gym, YMCA and many others have developed elegant initiatives to induce an increase in physical activity. But once obesity has been achieved by an individual these prevention measures are too late – ideal for the next generation, but not for this one. The evidence for diet, psychological input and physical activity changes is poor in inducing long-term weight loss, and currently there is one prescribable weight loss agent, which is only moderately useful. Obesity leads to diabetes, heart disease, stroke, cancer, sleep apnoea and premature death.
Bariatric surgery is the only permanent intervention that has been shown to cause remission of co-morbidities in the long term, and must be embraced by commissioners for increasing numbers of high risk individuals, and not consigned to history.
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