Dr. Sharma's Obesity Notes

With the ever-increasing number of patients undergoing bariatric surgery, it is not surprising that professional organisations around the world are publishing a slew of recommendations and guidelines on how best to manage these patients.

The latest guideline on this topic appears this month in the Journal of Clinical Endocrinology and Metabolism, the official journal of The Endocrine Society.

The 20-page guideline, authored by a panel led by David Heber (University of California), focusses on the immediate postoperative period and long-term endocrine and nutritional management of the post-bariatric surgery patient.

As expected, the key challenges are to prevent complications, weight regain, and progression of obesity-associated comorbidities.

As the panel notes, bariatric surgery is by no means a guarantee of successful weight loss or maintenance and all patients require care from a multidisciplinary team including an experienced primary care physician, endocrinologist, or gastroenterologist (I would add a general internist to this list) and must consider enrolling postoperatively in a comprehensive program for nutrition and lifestyle management.

The guidelines also point out that while nutritional risks are greatest with malabsorbtive procedures (e.g. Roux-en-Y gastric bypass), the risk for weight regain are highest for purely restrictive procedures (e.g. adjustable gastric banding).

Nutritional education and clinical management to prevent and detect nutritional deficiencies are recommended for all patients undergoing bariatric surgery (including those with purely restrictive procedures) and should focus on adequate protein, vitamin, and mineral intake.

The guidelines contain particularly comprehensive sections dealing with the causes of weight regain, management of patients with diabetes mellitus, and issues related to bone health, gout, gastrointestinal problems, and eating behaviour.

All clinicians involved in this rapidly evolving field of medicine will likely find these latest guidelines a quick and worthwhile read.

AMS
Edmonton, Alberta

Heber D, Greenway FL, Kaplan LM, Livingston E, Salvador J, & Still C (2010). Endocrine and nutritional management of the post-bariatric surgery patient: an endocrine society clinical practice guideline. The Journal of clinical endocrinology and metabolism, 95 (11), 4823-43 PMID: 21051578

As I was flying out to the 4th Annual Obesity Network Obesity Boot Camp yesterday (more on the camp later), I happened to read this week’s Globe Essay by Arthur Kleinman titled, “Health Care’s Missing Care”.

Arthur Kleinman is professor of medical anthropolgy at Harvard University and in his essay, he deplores the loss of caregiving in today’s clinical practice. He calls this the lost art of medicine, displaced by ever-more emphasis on economically-driven concepts of “evidence-based” rationalisation and increasing reliance on science and technology for diagnosis and treatment.

He asks:

“What time has been allotted for aquiring this skill [of caregiving] in medical school and residency training? What has been done to evaluate future doctors’ skills in this respect? Has medicie turned its back on the medical art and the thousands of years of humanistic approaches to medical practice?”

In his essay he focuses on the frail and elderly, but much of what he discusses is as applicable to my bariatric patients, as it is to patients in many other fields of medicine:

“…for example, we can say that caregiving begins with the ethical act of acknowledging the situation of the sufferer, affirmig his or her efforts and those of family and friends to respond to pain and impairment, and demonstrating emotional and moral solidarity with those efforts.”

“It moves on to involve the physician in pain management, symptom relief, treatment of other “intercurrent” diseases (such as depressive disorder) that may arise during the first disease, and judicious management of the use of pertinent technology and control of unnecessary or futile interventions.”

“It includes working with a network of other health care professionals (such as physical therapists, occupational therapists, nurses, social workers, and home health-care assistants), and family and network of care givers.”

“It means spending real time with patients, empathically listening to their illness narratives, eliciting and respondig to their explanatory models, and engaging the psychosocial coping processes involved in enduring or ending life.”

I can only concur with Kleinman as he concludes that,

“The physician’s art – now so circumscribed by bureaucratic, political and economic forces – turns on both the professionalization of these inherently human resources and the impact of their routine use on the doctor’s own moral life.”

Working in a clinic where we currently look after over 1,500 patients (not to mention the over 2,000 patients on the waiting list) struggling with body weights, not seldom well over 400 lbs, these words ring only too true.

While we may not have the “magic bullet” for severe obesity, we can certainly offer compassion and understanding on how living with this cruel and devastating condition requires unbelievable daily courage and struggle.

Let us never forget who we serve!

AMS
Station Dushesnay, Quebec

Yesterday, I attended a workshop hosted by the Canadian Institute of Circulatory and Respiratory Health in Ottawa on harmonisation of clinical practice guidelines in cardio-respiratory diseases.

Once again, I was reminded of the tremendous amount of work required to produce guidelines based on the best published evidence. As readers of this blog are probably well aware, we have Obesity Clinical Practice Guidelines in Canada, published in 2006, available online from CMAJ.

Readers with a particular interest in bariatric surgery should be aware of the new comprehensive guidelines for the perioperative nutritional, metabolic, and non-surgical support for the bariatric surgery patient jointly published by the American Association of Clinical Endocriologists, The Obesity Society, and the American Society for Metabolic and Bariatric Surgery, also published as a supplement to this month’s issue of OBESITY.

The Writing Committee was co-chaired by Jeffrey Mechanik, Robert Kushner and Harvey Sugerman with broad representation from all three organizations.

The guidelines include over 164 recommendations covering everything from indications and patient selection to nutritional and metabolic management and complications. Recommendations are ranked and rated based on the level of evidence that supports them (an Appendix discusses the relevant clinical evidence extracted from almost 800 references).

Certainly required reading for anyone caring for patients planning to or having recently undergone bariatric surgery.

AMS
Edmonton, Alberta

On the last day of the 2008 Scientific Meeting of The Obesity Society (TOS), Phoenix, Arizona, I attended a session on bariatric surgery (for non-surgeons). Not only is this a clear indication that TOS is moving closer to the bariatric surgery community, but also that the surgeons are recognizing the importance of reaching out to the non-surgery bariatric health professionals, whose support is essential for the long-term success of patients undergoing bariatric surgery.

As readers of this blog know, we may be ahead of the game in this regard, as the Canadian Association of Bariatric Physicians and Surgeons (CABPS) was created right from the onset to ensure that the surgical and non-surgical strategies and approaches go hand in hand.

Canada can perhaps also point to the comprehensive evidence-based 2006 Clinical Practice Guidelines for obesity prevention and management, that includes chapters on behavioural, medical and surgical management of obesity.

That said, given the exponential increase in the demand and delivery of bariatric surgery in the US, the Americans are of course further along in terms of developing extensive guidelines specifically centred around the care of bariatric patients.

Two recent documents that readers of these pages may be interested in are:

- Medical Guidelines for Clinical Practice for the Perioperative, Nutritional,  Metabolic and Non-Surgical Support of the Bariatric Surgery Patients, co-published by the American Association of Clinical Endocrinologists, The Obesity Society, and the American Society for Metabolic and Bariatric Surgery.

- ASMBS Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient, which provides an overview and should serve as an educational tool to increase awareness among medical professionals of the potential risk of nutritional deficiencies common to bariatric surgery patients.

The wealth of information in these documents should dispel any false notion that bariatric surgery is a “simple” and “easy” solution to obesity. 

As blogged before, obesity surgery is not just about surgery.

AMS
Edmonton, Alberta

Yesterday, the Globe and Mail wrote an extensive article on Dr. Sean Wharton, an internist, who runs a clinic that delivers a full range of bariatric medical care within the Ontario public health care system.

I was particularly pleased to see this portrayal of Dr. Wharton’s clinic, as I had the pleasure of training him during my time in Hamilton. Joining me as a young doctor, just on the verge of completing his training in internal medicine, he quickly gained an appreciation of and a remarkable competency in bariatric medicine. He recognized that patients challenged with excess weight are as deserving as patients with any other medical condition, with the difference that they have nowhere to go.

Dr Wharton is also a graduate of the 2006 Canadian Obesity Network Obesity Boot Camp.

On May 1 of this year, he started the Wharton Medical Centre in Hamilton, dedicated to providing Government-funded speciality bariatric care.

The Clinic has recently expanded to over 5000 square feet and now approximately 1500 active patients.

The Clinic Staff includes 3 Internists, 2 nephrologists, and 2 family physicians, as well as bariatric technicians, cardiovascular technicians, clinic research staff, a dietitian, behavioural therapists, kinesiologist, and administrators.

The clinic provides a full range of bariatric care in individual and group settings at no charge to the patient. Up to 5-10 classes per week address topics such as emotional eating, body image, pre- and post-bariatric surgery support, meal planning, label reading, exercise classes and more.

While the G&M article focuses on the progress of a couple of extremely large patients, the clinic is open to anyone who needs to manage their weight for health reasons.

Although Dr. Wharton’s model may be unique, it certainly proves that at least interested specialists can provide comprehensive bariatric care within the public health care system in Ontario.

AMS
Edmonton, Alberta