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New European Guidelines on Medical Management After Bariatric Surgery

The European Association for the Study of Obesity (EASO) had now released the new OMTF guidelines Practical Recommendations of the Obesity Management Task Force of the European Association for the Study of Obesity for Post-Bariatric Surgery Medical Management.

The guidelines provide the latest guidance on nutritional management, micronutrient supplementation, managing co-morbidities, pharmacotherapy, psychological management, and prevention and management of weight regain. The guidelines also address the issue of post-bariatric surgery pregnancy.

Not covered are issues related to dealing with excess skin and rehabilitation (e.g. return to work, reintegration in social activities, education, etc.), both of significant importance, especially in people with severe obesity.

As the authors note,

“Bariatric surgery is in general safe and effective, but it can cause new clinical problems and it is associated with specific diagnostic, preventive and therapeutic needs. Special knowledge and skills of the clinicians are required in order to deliver appropriate and effective care to the post-bariatric patient. A post-bariatric multidisciplinary follow-up programme should be an integral part of the clinical pathway at centres delivering bariatric surgery, and it should be offered to patients requiring it”

These guidelines are now available open access in Obesity Facts.

Edmonton, AB


Better Fat Than Unfit

The 2018 JAMA special issue on obesity also includes a brief paper by Ann Blair Kennedy and colleagues reviewing the debate (which really isn’t much of a debate to anyone who knows the data) on whether it is more important to be fit than to worry about being fat (it is).

As the authors review, there is now ample data showing that cardio-respiratory fitness (CRF) is far more important for the prediction of cardiovascular mortality than the level of fatness (measured as BMI or otherwise).

In fact, once you account for differences in “fitness”, actual BMI levels almost cease to matter in terms of predicting longevity.

Unfortunately, as the authors point out, most studies linking obesity to cardiovascular outcomes (including studies on the so-called obesity “paradox”), fail to properly measure or account for cardiovascular fitness, thereby ignoring the most important confounder of this relationship.

For clinicians (and anyone concerned about their excess weight), it is helpful to remember that while achieving and maintaining a significant weight loss is a difficult (and often futile) undertaking, achieving and maintaining a reasonable degree of cardiorespiratory fitness is possible at virtually any shape or size.

Thus, as the authors point out,

“…in current US society, many people progressively gain weight and lose CRF as they age. Conceivably, maintaining CRF may be more important than preventing the development of obesity. However, for people who are overweight or have mild to moderate obesity, there are effective ways to improve CRF, including exercise and lifestyle interventions and there is general agreement that having low levels of PA is unhealthy. Increasing PA to help keep individuals from becoming unfit can be achieved if patients meet current PA guidelines of 150 minutes of moderate or 75 minutes of vigorous PA per week.”

Clearly, if your primary concern related to your patients’ excess body fat is about their cardiovascular health, you would probably be doing them a far greater service by getting them to improve their cardiorespiratory fitness rather than simply lose a few pounds (and no, exercise is not the best way to lose weight!).

On the other hand, if there are other health issues that are of primary concern (e.g. sleep apnea, osteoarthritis, fatty liver disease, etc.) or the degree of excess fat significantly affects mobility or other aspects of quality of life, then perhaps a frank discussion about available and effective “weight-loss” treatments appears warranted.

Let us not forget that it is never a good idea to simply treat numbers on the scale.

Edmonton, AB


Long-Term Health Outcomes After Bariatric Surgery

Another series of articles in the 2018 JAMA special issue on obesity, deals with the impact of bariatric surgery on health outcomes and overall mortality.

The first article by Sayeed Ikramuddin and colleagues is an observational follow-up of a randomized clinical trial at 4 sites in the United States and Taiwan, involving 120 participants who had a hemoglobin A1c(HbA1c) level of 8.0% or higher and a BMI between 30.0 and 39.9. The study compared intensive lifestyle and medical management intervention based on the Diabetes Prevention Program and LookAHEAD trials for 2 years, with and without (60 participants each) Roux-en-Y gastric bypass surgery followed by observation to year 5.

At 5 years, 13 participants (23%) in the gastric bypass group and 2 (4%) in the lifestyle-intensive medical management group had achieved the composite triple end point (HbA1c less than 7.0%, LDL cholesterol less than 100 mg/dL, and systolic blood pressure less than 130 mm Hg).

In the fifth year, 31 patients (55%) in the gastric bypass group vs 8 (14%) in the lifestyle–medical management group achieved an HbA1c level of less than 7.0%.

As is to be expected, surgical treatment resulted in more serious adverse events (66 vs 38 events), most frequently involving gastrointestinal and surgical complications such as strictures, small bowel obstructions, and leaks.

A second study by Gunn Signe Jakobsen and colleagues from Norway, reports on changes in obesity related comorbidities in patients with severe obesity (BMI ≥40 or ≥35 and at least 1 comorbidity) undergoing bariatric surgery (n=932, 92 gastric bypass) or specialized medical (“lifestyle”) treatment (n=956) at a tertiary care outpatient center.

Based on drugs dispensed according to the Norwegian Prescription Database and data from the Norwegian Patient Registry and a local laboratory database, surgically treated patients had a greater likelihood of remission (RR, 2.1) and lesser likelihood for new onset of hypertension (RR, 0.4), a greater likelihood of diabetes remission (RR, 3.9) but also a greater risk of new-onset depression (RR, 1.5) and treatment with opioids (RR, 1.3.

Again, as expected, surgical patients had a greater risk for undergoing at least 1 additional gastrointestinal surgical procedure (RR, 2.0).

From these findings the researchers conclude that adding gastric bypass to lifestyle and intensive medical management alone in patients with severe obesity and type 2 diabetes, there remained a significantly better composite triple end point in the surgical group at 5 years.

The third study by Orna Reges and colleagues from Israel, was a retrospective cohort study in a large Israeli integrated health fund database, that compared 8,385 patients who underwent bariatric surgery compared to 25,155  nonsurgical patients matched on age, sex, BMI, and diabetes. The surgical interventions included laparoscopic banding [n = 3635], gastric bypass [n = 1388], and laparoscopic sleeve gastrectomy [n = 3362]

Over the approximately 4.5-year follow up period, there were 105 deaths (1.3%) among surgical patients compared to 583 deaths (2.3%) among nonsurgical patients.

Mortality rates were similar across the different types of surgery: [1.7%] who underwent laparoscopic banding, 18 [1.3%] gastric bypass, and 26 [0.8%] sleeve gastrectomy).

Form these findings the authors conclude that, compared with usual care, nonsurgical obesity management, was associated with lower all-cause mortality.

Finally, a fourth paper by Sarah Shubeck and colleagues from the University of Michigan, discuss the finding of a study by Anita Courcoulas and colleagues published in JAMA Surgery, which describes 7-year weight trajectories and health outcomes in the Longitudinal Assessment of Bariatric Surgery (LABS) Study that includes 1738 patients who underwent Roux-en-Y gastric bypass (RYGB) and 610 patients who underwent laparoscopic adjustable gastric banding (LAGB).

At 7 years, patients who had undergone RYGB  lost 28% of initial weight with minimal weight regain between years 3 and 7 (3.9%) compared to patients who had undergone LAGB  (14.9% weight loss with 1.4% regain).

Patients who had undergone RYGB benefitted from high rates of long-term relief from all 5 comorbidities evaluated (diabetes mellitus, high LDL cholesterol, high triglycerides, low HDL cholesterol level, and hypertension) at 7 years than those who had undergone LAGB.

Importantly, postprocedure mortality was very low with 3 deaths within 30 days of surgery and 7-year death rates of 3.7/700 person-years after RYGB (59 deaths) and 2.7/700 person-years after LAGB (15 deaths). Rates of operative revisions and reversals were low for patients in the RYGB group (0.92/700 person-years), but were significantly higher among patients in the LAGB group (30.29/700 person-years).

Taken together, all 4 studies document the considerable long-term health benefits associated with surgical treatment of severe obesity but also note that there are certain surgical risks (which vary between procedures) that need to be individually discussed with patients.

Edmonton, AB


Gastric Bypass Vs. Sleeve Gastrectomy For Severe Obesity

In the 2018 special issue of JAMA on obesity, two research articles compare long-term outcomes (5 years) after laparoscopic roux-en-Y gastric bypass (RYG) to sleeve gastrectomy (SG).

In the first study by Ralph Peterli and colleagues from Switzerland, the authors report on the findings from the  Swiss Multicenter Bypass or Sleeve Study (SM-BOSS), a 2-group randomized trial, that included 217 patients at 4 bariatric centres, who were enrolled and randomly assigned to SG or RYG.

At 5 years, weight loss was slightly greater in the RYG group but this difference was not statistically significantly.

Gastric reflux improved more after RYG and was more likely to worsen with SG. Reoperation rates were marginally higher in the RYG group (seven reoperations after sleeve gastrectomy were for severe GERD, and 17 reoperations after bypass were for internal hernias) .

In the second study Paulina Salminen and colleagues from Finland report on the  Sleeve vs Bypass (SLEEVEPASS) multicenter, multisurgeon, open-label, randomized clinical equivalence trial which randomly assigned patients with severe obesity to SG (n=121) or RYG (n=119)  with a 5-year follow-up period.

At 5 years, weight loss, remission of diabetes, as well as improvements in dyslipidemia and hypertension were slightly higher in the RYG group than in the SG group.

Overall, there was no difference in improvement in quality of life or in morbidity rates between the two groups. There was no treatment-related mortality in either group.

In an accompanying editorial, David Arterburn and Arniban Gupta from the University of Washington, Seattle, note that,

“Collectively, these studies provide reassuring data to suggest that the rapid switch from Roux-en-Y gastric bypass to sleeve gastrectomy in the last decade has not been a therapeutic misadventure similar to the rise and fall of the adjustable gastric band,5 which has been all but abandoned.”

They also point to five important learnings from these studies:

  1. Patients should be informed that deciding between sleeve gastrectomy and bypass is complex and requires patients to simultaneously consider information about many factors, including weight loss, control of different comorbidities, and short- and long-term risks.
  2. Weight loss between the two procedures are more or less on par.
  3. GS may be a reasonable choice even for patients with diabetes.
  4. Patients with GERD deserve careful consideration, because their outcomes are differentially affected by sleeve gastrectomy and gastric bypass.
  5. Given the relative parity between these procedures in weight loss and comorbidity resolution, shared decision making conversations should prioritize discussion of individual risk tolerance and preferences, ie, which potential risk or consequence is more acceptable to the patient—the risk of reoperation for GERD with sleeve gastrectomy vs the risk of reoperation for a small bowel obstruction or internal hernia with bypass.

Ultimately, deciding between the two procedures is not easy and warrants an in-depth discussion between patients and their surgeons.

Edmonton, AB






The OPQRST Of Body Weight

The assessment of weight history is no doubt a key feature of obesity assessment. Not only can weight history and trajectories provide important insights into obesity related risk but, perhaps more importantly, provide key information on precipitating factors and drivers of excessive weight gain.

Now, in a short article published in MedEdPublish, Robert Kushner discusses how the well-known OPQRST mnemonic for assessing a “chief complaint”  can be applied to assess body weight.

In short, OPQRST is a mnemonic for Onset, Precipitating, Quality of Life, Remedy, Setting, and Temporal pattern. Applied to obesity, Kushner provides the following sample questions for each item:

Onset: “When did you first begin to gain weight?” “What did you weight in high school, college, early 20s, 30s, 40s?” “What was your heaviest weight?”

Precipitating: “What life events led to your weight gain, e.g., college, long commute, marriage, divorce, financial loss?” “How much weight did you gain with pregnancy?” “How much weight did you gain when you stopped smoking?” “How much weight did you gain when you started insulin?”

Quality of life: “At what weight did you feel your best?” “What is hard to do at your current weight?”

Remedy: “What have you done or tried in the past to control your weight?” “What is the most successful approach you tried to lose weight?” “What do you attribute the weight loss to?” “What caused you to gain your weight back?”

Setting: “What was going on in your life when you last felt in control of your weight?” “What was going on when you gained your weight?” “What role has stress played in your weight gain?” “How important is social support or having a buddy to help you?”

Temporal pattern: “What is the pattern of your weight gain?” “Did you gradually gain your weight over time, or is it more cyclic (yo-yo)?” “Are there large swings in your weight, and if so, what is the weight change?”

As Kushner notes,

“These features provide a contextual understanding of how and when patients gained weight, what efforts were employed to take control, and the impact of body weight on their health. Furthermore, by using a narrative or autobiographical approach to obtaining the weight history, patients are able to express, in their own words, a life course perspective of the underlying burden, frustration, struggle, stigma or shame associated with trying to manage body weight. Listening should be unconditional and nonjudgmental. By letting patients tell their story, the clinician is also able to assess the patients’ awareness, knowledge, motivation, decision-making, and resiliency regarding weight management. The narrative provides a basis for approaching the patients’ weight holistically, as well as beginning to formulate diagnostic and therapeutic options.”

There is no doubt much to be gained in understanding obesity by allowing patients to tell their own weight stories.

Berlin, D