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.
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
For all my Canadian readers (and any international readers planning to attend), here just a quick reminder that the deadline for early bird discount registration for the upcoming 4th Canadian Obesity Summit in Toronto, April 28 – May 2, ends March 3rd.
To anyone who has been at a previous Canadian Summit, attending is certainly a “no-brainer” – for anyone, who hasn’t been, check out these workshops that are only part of the 5-day scientific program – there are also countless plenary sessions and poster presentations – check out the full program here.
To register – click here.
It would hardly come as a surprise to regular readers that I would be delighted to see the Edmonton Obesity Staging System featured quite prominently in the article on obesity management by Dietz and colleagues in the 2015 Lancet series on obesity.
Here is what the article has to say about EOSS:
“The Edmonton obesity staging system (EOSS) has been used to provide additional guidance for therapeutic interventions in individual patients (table 1). EOSS provides a practical method to address the treatment paradigm. In principle, EOSS stages 0 and 1 should be managed in a community and primary care setting. Recent data from the USA suggest that 8% of patients with severe obesity (BMI ≥35 kg/m²) account for 40% of the total costs of obesity, whereas the more prevalent grade 1 obesity accounts for a third of costs. These findings suggest that greater priority should be accorded to EOSS stages 3 and 4, resulting in greater focus on pharmacological and surgical management delivered in specialist centres.”
These recommendations are not surprising, as EOSS was specifically designed to provide a much better representation of how “sick” a patient is rather than just how “big” she is.
This is why EOSS has now found its way not just into the 5As of Obesity Management framework of the Canadian Obesity Network but also into the treatment algorithm of the American Society of Bariatric Physicians.
To download a slide presentation on how EOSS works click here.