Studying Bariatric Care in Newfoundland
Having spend the last few days attending the Canadian Nutrition Society’s Annual Meeting in Quebec City, I am now in St. John’s Newfoundland for a CIHR-sponsored meeting on bariatric care research hosted by Laurie Twells from Memorial University. According to various surveys, Newfoundland and Labrador has the highest prevalence of obesity (although some folks think that this may just be because Newfoundlanders are simply more honest in reporting their actual heights and weights), reason enough to dedicate resources at Memorial University but also within the healthcare system to better managing children and adults with excess weight. In a recent paper published in Population Health Management, Twells and colleagues, using health service utilization data from Newfoundland and Labrador, showed that individuals with a BMI greater than 35 had a significantly higher number of visits to a general practitioner over a 5-year period compared to the normal weight group (median 22 vs. 17, P<0.05) but were no more likely to visit a specialist or use hospitals, despite a greater prevalence of health problems. The reasons for this are not clear but may speak to the reluctance of individuals with more severe obesity to seek specialised care or perhaps to the fact that their doctor’s are less likely to refer them for such care – a finding that has been reported before in other jurisdictions. At the planning meeting, we will be focussing on further developing a research agenda for the fledgling bariatric surgery program that was recently started in St. John’s but will likely also discuss other research questions related to health services for individuals living with excess weight in Atlantic Canada. I look forward to an interesting meeting. AMS St. John’s, Newfoundland p.s. I also get to do another “Dr. Sharma Show” tomorrow night (June 4, 7.00 pm).
Hindsight: Managing Weighty Issues on Lean Evidence
In 2005, I wrote an article for the Canadian Medical Association Journal (CMAJ), in which I highlighted that fact that in light of the obesity epidemic, physicians and other health care workers will be delivering health care to a growing number of obese and severely obese patients. “Diagnosing many common medical conditions, although straightforward in nonobese patients, can be fraught with difficulty in morbidly obese people because little is known about the sensitivity and specificity of diagnostic tests in this population. …obtaining imaging studies such as CT or MRI is often impossible for morbidly obese patients because of the size and weight limitations of the machines. Oversized equipment is unavailable in most hospitals. These limitations call for more research into diagnostic algorithms, tests and reference ranges for morbidly obese patients, to avoid misdiagnoses and to ensure optimal care.” I also noted that with the exception of ‘weight-loss studies’, people with obesity are generally underrepresented in clinical trials. “As a result, the majority of clinical practice guidelines, even for conditions commonly found in obese patients (e.g., hypertension, diabetes mellitus, asthma, ischemic heart disease, venous thrombosis and neuropsychiatric disorders) fail to make specific recommendations for patients with morbid obesity that go beyond a rather general appeal for weight loss. This issue is far from trivial, as obesity significantly affects the pathophysiology and pharmacodynamic response in a multitude of medical conditions. For example….gastroesophageal reflux disease, where the pathophysiology in obese patients (increased intra-abdominal pressure, hiatal hernia, vagal abnormalities) may be distinctly different from that in nonobese patients. Responses to medications may be different, as metoclopramide may fail to decrease gastric volume or raise pH in obese patients. Similarly, although self-reported asthma is more frequent at higher BMI levels, obese individuals paradoxically are at lowest risk for significant airflow obstruction, and much of the respiratory symptoms may indeed be due to nocturnal aspiration of gastric reflux. Thus, asthma not only may be overdiagnosed in the obese population but, if present, may require a different approach to management.” I also commented on the need for studies that examine the effects of excess weight on pharmacokinetics and pharmacodynamics of medications commonly used in obese patients. “Virtually all existing diagnostic criteria and algorithms will need to be revalidated in the obese population, and where physical limitations hinder the use of diagnostic imaging technology, new strategies will have to be developed to deal with very obese people…. In… Read More »
Unhealthy Waits?
One of the limitations of a publicly funded health system is extended wait times, not least for individuals, who struggle with severe obesity. How do such wait times affect these patients’ health and how do they feel about it? This is the topic of a paper we now publish in BMC Health Services Research. In order to better understand wait-listed patients’ health status and perceptions regarding the consequences of prolonged wait times, we used a cross-sectional study design nested within a prospective cohort study. Participants were 150 consecutive consenting subjects wait-listed for a tertiary care multi-disciplinary bariatric assessment in an Alberta population-based medical/surgical bariatric program. We measured health status using a visual analogue scale and used the Waiting List Impact Questionnaire (WLIQ) to look at the impact on employment, physical stress, social support, frustration, quality of life, and satisfaction with care. All analyses were adjusted for age, sex and BMI identified independent predictors of lower VAS scores. Over 90% of participants were women with a mean age of 43, mean BMI of 50 and an average waiting time (at the time of assessment) of 64 days. The mean health VAS score was 53/100), whereby independent predictors of lower VAS scores included a higher BMI, unemployment and depression (sleep apnea just missed statistical significance in this analysis). This level of VAS score is markedly lower than the average score of 85 previously reported in a random sample of community-dwelling adults drawn from the same population as our study sample and even considerably lower than those reported other chronic medical conditions such as diabetes and COPD with VAS scores of 66 and 65 respectively. Physical limitations were common, with 85% reporting reduced activity, 83% reporting activity limitations compared to previous activity levels and 69% reporting worsening physical limitations over time. The majority of subjects expressed concern over wait times (65%) and felt that waiting was very stressful (53%) and physically, emotionally and mentally taxing (62%). According to the WLIQ, 47% of subjects agreed or strongly agreed that waiting affected their quality of life, 65% described wait times as ‘concerning’ and 81% as ‘frustrating’. Of the respondents, 81% of subjects indicated that the wait for care was frustrating, 73% worried about the consequences of extended wait times on their health, 68% were frustrated with the allocation of resources and 59% felt that they should not have to wait for obesity treatment. Surprisingly, however,… Read More »
Challenges in the Medical Management of Severe Obesity
I am currently attending the 19th European Congress on Obesity, here in Lyon, France, where yesterday, I spoke on the medical management of severe obesity. Rather than repeating my take on this, I would prefer to quote the following passage from today’s Close Concerns newletter, that covers my talk (and the rest of the session). After characterizing the increasing prevalence of severe obesity (BMI >40 kg/m2), the burdens it places on patients and the healthcare system, and the challenges of its management, Dr. Sharma discussed potential lifestyle and pharmacologic for consideration for the treatment of severe obesity. He mentioned that medically supervised low-calorie diets could in rare cases be an option for long-term weight management for highly motivated patients with severe obesity, while pharmacologic agents in development are slowly getting to the point where they could be efficacious enough to move the needle. Dr. Sharma noted that conservative management (using a combination of intensive lifestyle, medication, and a low-calorie diet) could help approximately 20-30% of individuals to achieve and sustain clinically meaningful weight loss in a clinical setting. Obesity places numerous burdens on patients, spanning the four M’s: metabolic, monetary, mental, and mechanical. Dr. Sharma noted that in his practice, severely obese patients who are referred for bariatric surgery undoubtedly face these burdens – 75% suffer from depression, approximately one-third experience mechanical problems (e.g., osteoarthritis, sleep apnea), a large percentage has cardiometabolic issues (e.g., diabetes and/or hypertension), and approximately one-fifth are on long-term disability or unemployed (even though it is a relatively young population; average age of 44 years). Dr. Sharma highlighted the burdens that severe obesity places on the healthcare system. Dr. Sharma noted that severe obesity decreases post-acute rehabilitation efficiency, increases hospital lengths of stay, and increases hospital costs. Specifically, at the Glenrose Rehabilitation Hospital in Canada, rehabilitation length of stay was on average 56 days for severely obese individuals compared to non severely obese individuals, and rehabilitation costs averaged $115,000 versus $44,000. These stem from the fact that severely obese patients waited on average 43 days to transfer to another facility, whereas other patients waited zero days on average. He emphasized that while bariatric surgery is the most effective option for the treatment of severe obesity, it is by no means a population-level solution for two reasons: 1) many do not want to undergo surgery, are ineligible to do so, or do not have access; and 2)… Read More »
Impact of Severe Obesity on Post-Acute Rehabilitation Costs
Some of the greatest advances in modern medicine are in the field of rehabilitation – from accident victims to individuals with strokes and heart attacks, diligently working with patients to restore their health and function can be time consuming, resource intensive, but also immensely rewarding to patients, their families, and society. Unfortunately, when patients are also severely obese, costs and duration of rehabilitation dramatically increase. Thus, in a paper we recently published in the Journal of Obesity, we looked at the impact of severe obesity on post-acute rehabilitation efficiency, length of stay, and hospital costs. We retrospectively looked at these parameters in 42 severely obese subjects (mean age 53 y; mean BMI 50.9) and compared them to 42 nonobese controls (mean age 59 y; mean BMI 23.0) matched by sex and admitting diagnosis. Although in the end the severely obese subjects achieved the same functional independence measure as the lean controls (0.58 vs. 0.67), they experienced longer total length-of-stay (98.4 vs. 37.4 days), rehabilitation length-of-stay (55.8 vs. 37.4 days), and waiting for transfer (42.6 vs. 0 days). This resulted in almost a three-fold increase in hospital costs ($115,822 vs. $43,969). It is apparent from these findings that the most significant determinant of higher costs in severely obese rehab patients is not the cost for their treatment but their considerably longer length-of-stay after achieving their rehabilitation goals. As discussed in our paper, “We suspect that the increased waiting-for-transfer-of-service length-of-stay in the severely obese is a consequence of the patient’s inability to gain independence following rehabilitation. In our experience, these subjects cannot return home and due to a lack of suitable alternative discharge destinations, often wait in hospital for transfer to a nursing home.” This speaks to the lack of appropriate bariatric care facilities in nursing homes and the difficulties that severely obese patients may often face in their usual home and familial settings with even modest additional limitations that remain after the completion of in-patient rehabilitation. Indeed, few homes and personnel delivering home care are equipped or trained to deal with the special needs to individuals with severe obesity. We also discuss at length some of the considerable challenges that severely obese patients face whilst within the rehabilitation setting: “However there are very limited published data on bariatric-specific PAR interventions and this deficiency was recently recognized at a multidisciplinary consensus conference [hosted by the Canadian Obesity Network]. Many potential barriers to developing effective… Read More »
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