For patients with obesity and type 2 diabetes, bariatric surgery is by far the most effective treatment - it is, indeed, the only form of treatment that can put patients into full long-term remission.

But is surgery really a cost-effective option for health systems looking to contain the immense economic and health burden of diabetes?

A paper by Martin Makary and colleagues from Johns Hopkins University, Baltimore, just published in the Archives of Surgery, looks at the annual health care costs in patients with type 2 diabetes before and after bariatric surgery.

The researchers examined administrative claims data from 2235 adults with type 2 diabetes who underwent bariatric surgery in the US during from January 1, 2002, through December 31, 2005.

Surgery eliminated the use of anti-diabetes medication therapy in 75%, 81%, and 85% of patients at 6 months, 1 and 2 years, respectively.

Although the median cost of the surgical procedure and hospitalization was abut $30,000, in the 3 years following surgery, total annual health care costs, which increased by about 10% in the first year after surgery, decreased by around 35% in year 2 and by over 70% in year 3 compared to costs before surery.

As the authors point out, “Because weight loss following bariatric surgery has been observed to be sustained for decades, we believe that the protective effect against complications of diabetes is also likely to be long-term.”

This study of administrative data also supports the remarkable safety of bariatric surgery, which in this populations had an in-hospital mortality rate of only 0.3%.

The authors do not fail to point out the tremendous public health implications of these findings,

“Most concerning are the deferred health consequences and costs associated with obesity, auguring the presentation of complications decades into the future. Current trends in rates of obesity and diabetes threaten to overwhelm the already strained health care resources in many countries. Thus the obesity epidemic has created a deferred influx of demand for diabetes-related health care services not yet realized. Until a successful non-surgical means for preventing and reversing obesity is developed, bariatric surgery appears to be the only intervention that can result in a sustained reversal of both obesity and type 2 diabetes mellitus in most patients receiving it.”

An important limitation of the study is that it does not consider the long-term costs of diabetes complications like heart disease, renal failure, and amputations, that are likely to be prevented or at least substantially deferred as a result of surgery.

The report also does not consider the substantial additional savings that could incur from the prevention of obstetric and gynecological complications, such as gestational diabetes and poor fetal outcomes.

In addition, the weight loss experienced may prevent, stabilize, or improve other obesity-related conditions, such as urinary incontinence and osteoarthritis.

Bariatric surgery may also decrease complications after other surgical procedures (ie, orthopedic procedures).

Finally, there is also good evidence to support the notion that obesity surgery prevents cancers.

In light of these finding the authors conclude, “Health insurers, private and public, should pay for bariatric surgery for appropriate candidates, recognizing a potential annualized cost savings in addition to the benefit to health.”

Exactly how health service systems can rapidly increase availability of bariatric surgery for eligible patient (with all the necessary pre- and post-surgical management resources) remains to be seen.

However, any health care system that fails to look at this issue now, is likely to go under in the wake of the tremendous obesity costs that are poised to overrun all other health care costs in the foreseeable future.

AMS
Toronto, ON

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Makary MA, Clarke JM, Shore AD, Magnuson TH, Richards T, Bass EB, Dominici F, Weiner JP, Wu AW, & Segal JB (2010). Medication utilization and annual health care costs in patients with type 2 diabetes mellitus before and after bariatric surgery. Archives of surgery (Chicago, Ill. : 1960), 145 (8), 726-31 PMID: 20713923

Yesterday, University of Alberta’s John Spence (on faculty of the annual Canadian Obesity Network’s Student Boot Camp) together with Valerie Carson (former Bootcamper) and coworkers, published a most interesting article in BMC Public Health.

The paper looks at the uptake and effectiveness of the Children’s Fitness Tax Credit (CFTC) on Canadians. This tax credit was introduced by the Government of Canada in 2007 and allows a non-refundable tax credit of up to $500 to register a child in an eligible physical activity program.

A basic assumption of such tax rebates is of course, that they will help alleviate economic barriers that inhibit participation in physical activity.

Based on a 2009 survey of a representative sample of 2135 Canadians, around 55% of parents with children aged 2 to 18 years of age (n = 1004) stated their child was in organized PA and 55% were aware of the CFTC.

However, parents in the lowest income quartile were significantly less aware and less likely to claim the CFTC than other income groups. Thus, while only 28% of parents in the lowest income quartile had claimed the CFTC for the 2007 tax year, the tax credit was claimed by 55% of parents in the highest income quartile.

Parents in the highest income quartile were 2.5 times more likely than parents in lower income households to report their child being involved in organized physical activity, 4.1 times more likely to be aware of the CFTC, and around 3 times more likely to have claimed it for 2007 or were planning to claim it for 2008.

Among parents who had claimed the CFTC, only 16% believed it had actually increased their child’s participation in physical activity programs.

As Spence and colleagues discuss:

“It appears a tax credit such as the CFTC will only benefit those people who can afford to pay the costs of registration for a PA program and carry that burden through to the end of the tax year.”

These findings are in contrast to the Government of Canada’s objective that parents from “different circumstances” have equitable opportunity to benefit from the CFTC.

Basically, families at the lower end of the income continuum cannot afford the costs associated with organized PA and are less likely to be able to take advantage of a tax credit.

Therefore, if a tax credit is to be effective for all children, alternative solutions need to be sought for dealing with issues of inequity.”

Irrespective of what such a tax credit to increase physical activity will actually do for the obesity epidemic (the evidence is certainly not clear on this), this paper nicely illustrates how well-meant policies may often not have the intended effects for the population that needs it most.

AMS
Duchesnay, Quebec

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Spence JC, Holt NL, Dutove JK, & Carson V (2010). Uptake and effectiveness of the Children’s Fitness Tax Credit in Canada: the rich get richer. BMC public health, 10 PMID: 20565963

Born between 1982 and 1993, the kids of the Baby Boomers are sometimes also referred to as the Millennial generation, Generation Y, Net Generation, or Echo-Boomers.

This generation has fully embraced social networking (e.g. Facebook) and file sharing (e.g. Napster) and spends an average of 3.5 hours a day online. They have also been noted to live longer with and be more dependent on their parents while at the same time valuing flexibility and independence.

Importantly perhaps, up to one in three members of this generation in one third of the US States is now clinically obese.

As this generation enters the workforce, how will the obesity epidemic impact their economic health and expected earnings?

It may be reasonable to ask this question, as obesity will likely negatively impact their productivity and, as a result, their economic prosperity. Not only do obese individuals tend to miss more days at work but especially obese women have been shown to earn substantially lower wages (around 12% less) than their normal-weight counterparts.

This question of lifetime earning was now addressed by Shari Barkin and colleagues from Vanderbilt University, Nashville, TN, in a paper just published in the Journal of Business Psychology.

Utilizing evidence in the existing literature, the researchers created an economic model to predict the impact of obesity on the aggregate lifetime earnings for the Millennial generation and the consequences for employers and employees.

If the assumptions for this model hold true, Millennial US women will earn an average of $956 billion less due to obesity during their lifetime, whereas Millennial men will earn an average of $43 billion less. The overall impact of obesity on the aggregate lifetime earnings of Millennial men and women is close to one trillion dollars.

The enormous disparity of this impact on lifetime earnings between men and women is largely due to the much larger wage penalties payed by obese women compared to obese men and exist despite the fact that women’s labour participation rates and earnings tend to be less than men’s.

The article highlights the urgent need for employers to address the issue of obesity in the workplace and cites positive examples where employers (IBM, General Mills, Medtronic) have launched major initiatives aimed at improving the health of their workforce.

The authors also suggest that these interventions should perhaps be tailored to the characteristics of the Millenium generation by making full use of social networking and online strategies based on chronic disease management models.

Whether or not the assumptions underlying the model are completely true or not, the study does highlight the potential impact of obesity on this generation and the substantial fallout that this can have on the economic future of the US.

Similar impacts of obesity on the economics of other countries are only to be expected.

AMS
Edmonton, Alberta

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Barkin SL, Heerman WJ, Warren MD, & Rennhoff C (2010). Millennials and the World of Work: The Impact of Obesity on Health and Productivity. Journal of business and psychology, 25 (2), 239-245 PMID: 20502510

In Canada, demand for bariatric surgery outstrips access by around 600-fold (and that is probably a conservative estimate).

Of course, if you have the money, you can always go to one of the rapidly increasing number of Canadian private centres for an adjustable gastric band. You can perhaps also grab your check book and hop on a plane for surgery in the US or Mexico.

However, if there is no way you can come up with the cash, then it’s pretty much a waiting game in the public system with reported waiting times exceeding several years in most provinces.

But here is an interesting observation we just published in Obesity Surgery showing that even in a publicly funded clinic, folks with lower income are less likely to get surgery than people with higher socioeconomic status.

For this study Kieran Halloran, Raj Padwal, Carlene Johnson-Stoklossa, Daniel Birch and I performed a retrospective analysis of 419 patients who were seen in the Edmonton Weight Wise obesity clinic between 2005-2006 (which, admittedly, was long before I moved to Edmonton).

For this study, we arbitrarily defined all patients who were unemployed, on long-term disability or receiving social assistance as having a “low income” status. The remaining patients were categorized as “regular income” status.

Thirty-three (7%) patients were found ineligible for surgery or excluded because of missing income status data.

Of the remaining 386 patients, 72 (19%) were of low income status and 89 (23%) were approved for surgery, however, compared to patients of regular income status, those with low income status were 55% less likely to be approved for surgery (15.3% versus 24.8%).

Although, this may be suspected, we did not find that premature program termination or difference in attrition rates (60% at 6 months!) were significantly different between patients of low and regular income status as a possible explanation for our findings.

Notably, low income patients were older, heavier, and had greater comorbidity, but this was also not a major determinant of reduced chances of getting surgery. In fact, the inverse association between low income status and approval for surgery was actually stronger after adjustment for comorbidities.

Although mental illness was more common in patients of lower income status, it was also not predictive of approval for surgery. This is perhaps not surprising because of the emphasis placed on the management and stabilization of mental illness prior to proceeding with surgery in the Weight Wise program.

Thus, while our observations show that even within a publicly funded and universally accessible regional obesity program “lower income” status patients were substantially less likely to be approved for bariatric surgery than “normal income” patients.

The reasons for this remain unclear and certainly deserve further study.

Sensitivity to this apparent disparity and the exploration of program modifications to ensure equity across all socioeconomic strata is essential to ensure that all Canadians have timely access to appropriate bariatric care.

AMS
Edmonton, Alberta

p.s. Whether or not recent changes to the Edmonton Bariatric program have changed the impact of socioeconomic status on approval for bariatric surgery is currently being explored in the CIHR-funded APPLES study.

Halloran K, Padwal RS, Johnson-Stoklossa C, Sharma AM, & Birch DW (2010). Income Status and Approval for Bariatric Surgery in a Publicly Funded Regional Obesity Program. Obesity surgery PMID: 20401743

A study by Silvia Stinghini and colleagues from Villejuif, France, published in this week’s edition of JAMA re-examines the relationship between socioeconomic status and mortality in the famous British Whitehall study.

This longitudinal cohort study includes around 10,000 English civil servants, aged 35 to 55 years, 654 of whom have died since the study began 24 years ago.

When adjusted for sex and year of birth, civil servants in the lowest civil service employment grade (as a surrogate for socioeconomic status) had a 1.60 times higher risk of death from all causes than those with the highest employment grade. The risk for cardiovascular mortality was in fact 3 times higher for the lowest socioeconomic group.

However, this apparently strong impact of socioeconomic position declined remarkably when data was adjusted for repeated measures of health behaviours like smoking, alcohol consumption, diet, and physical activity.

Thus, when these behaviours were entered as time-dependent covariates the increased risk was reduced by 45% for cardiovascular mortality and 94% for noncancer and noncardiovascular mortality.

Thus clearly, a large part of the association between socioeconomic status and mortality is not due to the difference in socioeconomic status per se, but rather due to the poorer health behaviours associated with this status.

There are three possible inferences from these findings:

1) Poor people tend to make poor health “choices” because they are poor. (direct causality)

2) Poor people tend to be poor because they make poor health “choices”. (reverse causality)

3) Certain people tend to be both poor and make poor health “choices”. (no causality)

Reasoning 1) would imply that if people were less poor they would perhaps make better health “choices”.

Reasoning 2) would imply that if people made healthier “choices” they would perhaps be less poor.

Reasoning 3) would imply that that there is something else happening that makes people both poorer and (independently) more likely to make poorer health “choices”.

As pointed out in an accompanying editorial by James Dunn, McMaster University, Hamilton, Canada, most people tend to simplify the debate by explaining the poorer health “choices” of lower socioeconomic status with the greater “stress” of lower socioeconomic status.

But an emerging view could be that both health behaviours and lower socioeconomic status may well be independent expression of factors such as early childhood development, which are well known to affect self-regulation (the ability to guide goal-directed activities over time and across changing circumstances) or higher executive functions (like the skills involved in organisation, planning, self-monitoring, or self-control).

Deficits in these abilities or functions would not only make someone less likely to achieve a higher socioeconomic status but would also influence their ability to adopt and sustain healthy behaviours.

Obviously with obesity these lines of reasoning become far more complex. For e.g. in developing countries, it is often the people in the higher socioeconomic strata that gain weight. Even in Canada, middle class men rather than men in the lower economic group appear to be at higher risk for obesity.

Certainly interesting stuff to ponder on over the long weekend.

AMS
Edmonton, Alberta