Even, if one were to limit more intense obesity management (such as behavioral, pharmacological and/or surgical treatments) to those with more severe obesity (Edmonton Obesity Staging System 2+), this would still overwhelm the capacity of existing tertiary care systems.
Thus, as William Dietz and colleagues point out in their recent article in the 2015 Lancet Obesity Series, even the majority of severe (or complicated) obesity will still need to be managed in primary care.
“Care for adults with severe obesity has generally been delivered in tertiary-care centres. Although such programmes are efficacious, they are poorly suited to address the number of patients with severe obesity. Alternative approaches for the management of adults with severe obesity include primary-care settings or community settings to deliver care.”
“Transition from efficacy to effectiveness will require substantial and challenging changes in how primary care is delivered. Practices often lack the organisational structure, such as patient registries and methods for systematic tracking to assess clinical interventions, care teams to manage patients with chronic illnesses, or health information systems that support the use of evidence-based practices at the point-of-care to provide longitudinal care for chronic illnesses.”
Where they exist, these structures are already at capacity dealing with other chronic diseases including diabetes, hypertension, COPD and other lifelong disorders.
Even if many of these problems are directly related to excess weight (or would at least substantially improve with weight loss), most primary care practitioners have yet to take on the challenge of managing obesity (not just the obese patient).
Surely enthusiasm for obesity management will increase in primary care settings as more effective obesity treatments become available – making these available to those who stand to benefit, needs to be a key priority of health care system planners and payers.
The fact that many payers chose not to cover obesity treatments by delegating this to the category of “lifestyle”, shows that they have yet to take obesity seriously as a chronic disease in its own right.
It may also demonstrates their biases and discrimination of people living obesity – after all the same payers have no problem shelling out billions of dollars to treat other “lifestyle” disorders like strokes, heart attacks, type 2 diabetes or COPD.
This is where health policies can and should make a difference to people living with obesity – the sooner, the better.
In last week’s 2015 Lancet series on obesity, the majority of papers focus on policy interventions to address obesity. It suggests that a reframing of the obesity discussion, that avoids dichotomies (like nature vs. nurture debates) may provide a path forward – both in prevention and management.
The policy framework presented by Christina Roberto and colleagues in The Lancet, is based on the NOURISHING framework, proposed by the World Cancer Research Fund International to categorise and describe these actions.
Together, the actions in this framework address the food environment (e.g. food availability, taxation, restrictions on advertising, etc.), food systems (e.g. incentives and subsidies for production of healthier foods) and individual behaviour change (e.g through education and counselling).
This “food-centric” view of obesity is complemented by recognising that physical activity, much of which is dictated by the built environment and captivity of the population in largely sedentary jobs, also has a role to play.
On a positive note, the Christina and colleagues suggest that there may be reasons for careful optimism – apparently 89% of governments now report having units dedicated to the reduction of non-communicable diseases (including obesity), although the size and capacity of many of these units is unknown.
On the other hand, despite an increasing number of such efforts over the past decades, no country has yet reversed its epidemice (albeit there is a flattening of obesity growth rates in the lower BMI ranges in some developed countries – with continuing rise in more severe obesity).
Despite the potential role of government policies in reducing non-communicable diseases (including obesity) by “nudging” populations towards healthier diets and more physical activity, the authors also note that,
“…the reality is that many policy efforts have little support from voters and intended programme participants, and although the passage of policies is crucial, there is also a need to mobilise policy action from the bottom up.”
Indeed, there is growing list of examples, where government policies to promote healthy eating have had to be reversed due to lack of acceptance by the public or were simply circumvented by industry and consumers.
Nevertheless, there is no doubt that policies in some form or fashion may well be required to improve population health – just how intrusive, costly and effective such measures will prove to be remains to be seen.
All of this may change little for people who already have the problem. As the article explains,
“There are also important biological barriers to losing excess weight, once gained. Changes in brain chemistry, metabolism, and hunger and satiety hormones, which occur during attempts to lose weight, make it difficult to definitively lose weight. This can prompt a vicious cycle of failed dieting attempts, perpetuated by strong biological resistance to rapid weight loss, the regaining of weight, and feelings of personal failure at the inability to sustain a weight-loss goal. This sense of failure makes people more susceptible to promises of quick results and minimally regulated claims of weight loss products.”
Not discussed in the article is the emerging science that there may well be other important drivers of obesity active at a population level that go well beyond the food or activity environment – examples would include liberal use of antibiotics and disinfectants (especially in agriculture), decreased sleep (potentially addressable through later school start times and mandatory afternoon naps in childcare settings), increasing maternal age at pregnancy (addressable by better access to childcare), time pressures (e.g. policies to address time-killing commutes), etc.
Perhaps what is really needed is a reframing of obesity as a problem where healthy eating and physical activity are seen as only two of many potential areas where policies could be implemented to reduce non-communicable diseases (including obesity).
Some of these areas may well find much greater support among politicians and consumers.
Pregnancy in women after undergoing bariatric surgery are by no means uncommon. There is even some evidence from case series to suggest that babies born to mothers, who have undergone surgery may be less likely to become obese or experience the cardiometabolic complications of obesity.
This risk needs to be balanced against potential risks the known adverse effects of gastric bypass surgery on the metabolism of iron, vitamin B12, and folate,
Now a paper by Karl Johansson and colleagues, published in the New England Journal of Medicine, suggests that this may well be the case.
The researchers identified 627,693 singleton pregnancies in the Swedish Medical Birth Register from 2006 through 2011, of which 670 occurred in women who had previously undergone bariatric surgery and for whom presurgery weight was documented.
They found that pregnancies after bariatric surgery, as compared with matched control pregnancies, were associated with lower risks of gestational diabetes (1.9% vs. 6.8%; odds ratio, 0.25) and a lower incidence of large-for-gestational-age infants (8.6% vs. 22.4%; odds ratio, 0.33).
These potentially beneficial outcomes for the infant were counterbalanced by a two-fold increase in the likelihood of having a small-for-gestational-age infants (15.6% vs. 7.6%; odds ratio, 2.20) and a somewhat shorter gestation (mean difference -4.5 days)
Also, the risk of stillbirth or neonatal death was 1.7% versus 0.7% (odds ratio, 2.39).
No differences were found in the frequency of congenital malformations.
Bariatric surgery was associated with reduced risks of gestational diabetes and excessive fetal growth, shorter gestation, an increased risk of small-for-gestational-age infants, and possibly increased mortality.
Thus, the authors conclude that,
“…a history of bariatric surgery was associated with reduced risks of gestational diabetes and large-for-gestational-age infants.”
Nevertheless, they do recommend increased surveillance during pregnancy and the neonatal period, as bariatric surgery may also be associated with small-for-gestational-age infants, a shorter length of gestation, and potentially an increased risk of stillbirth or neonatal death.
Thus, soon, Canadians looking for medical treatment for obesity will soon have two prescription drugs available to them – the almost two decades old orlistat (Xenical®) and the soon to be launched liraglutide 3 mg (Saxenda®).
The differences between the two drugs could not be bigger. While orlistat works by inhibiting fat digestion and therefore reduces the number of calories absorbed from fat in the gut, liraglutide is a close analogue to human glucagon-like peptide 1, a gut hormone known to play a key role in insulin secretion and appetite regulation.
Because liraglutide is a peptide, it comes as a once daily injection, not unlike insulin. As an injectable prescription drug, Saxenda is not meant to be taken by anyone, who wants to quickly lose a few pounds. In fact, it takes several weeks of careful uptitration before you even reach the recommended dose for treating obesity – and, as with any obesity medication, you have to stay on it to keep the weight off.
According to Health Canada,
Saxenda® s indicated as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of:
- 30 kg/m2 or greater (obese), or;
- 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity (e.g., hypertension, type 2 diabetes, or dyslipidemia);
and who have failed a previous weight management intervention.
While seeing this approval is certainly a major step forward in our ability to medically treat obesity, liraglutide is neither effective for everyone nor will everyone tolerate it (the most common adverse effect is nausea). So, hopefully, this is only the first of several new anti-obesity drugs that we can expect to see in Canada in the coming years.
After all, there is no reason why we should not one day have as many drugs to treat obesity, as we have to treat other chronic diseases (e.g. hypertension, diabetes, etc.).
Disclaimer: I have received honoraria as a speaker and consultant from Novo Nordisk, the maker of Saxenda®.
This week I will be giving a key note address on the use of the Edmonton Obesity Staging System (and the shortcomings of BMI) at the 2015 Minimally Invasive Surgery Symposium (MISS) in Las Vegas.
Without doubt, minimally invasive laparoscopic surgery has revolutionised bariatric surgery – what was once a messy, life-threatening operation is now an elegant procedure, which usually has patients up and about the next day.
But are the BMI-based indications for bariatric surgery still the best way to go? Not when we have better systems like the Edmonton Obesity Staging System (EOSS) to determine how “sick” someone is rather than just how “big”.
This morning, in a separate presentation, I will also be providing an extensive overview on the efficacy and safety of the modern anti-obesity medications that have recently become available in the US.
While these medications may still not help patients achieve or maintain quite the degree of weight loss seen with surgery, they are certainly viable treatment options for individuals with less severe obesity or those unwilling or unable to undergo surgery.
Although evidence for this is still scarce, these medications may well also come to play a role in helping prevent the weight gain that some patients experience after surgery.
If nothing else, minimally invasive bariatric surgeons should certainly be aware of the available medical treatments as they counsel their patients about the pros and cons of surgery.
Las Vegas, NV