Hindsight: Bariatric Medicine Without Surgery is Like Nephrology Without Dialysis

One of the first articles I wrote after arriving in Canada as Canada Research Chair (Tier 1) in Cardiovascular Obesity Research and Management at McMaster University, was an editorial published in OBESITY SURGERY, in which I expressed my frustration about not having ready access to bariatric surgery for my patients, who desperately needed it.

In this article I noted that

“On accepting the position, I knew that I would be required to do some pioneering work: obesity or rather bariatric medicine is not a ‘recognized’ medical speciality. Rotation in an ‘obesity unit’ is neither a requirement nor of interest to the majority of medical residents. Most doctors’ understanding of obesity, its causes, its complications, and its management is not substantially different from that of a lay person. The well-known bias and discrimination that meets obese patients is also encountered in the commonly held views on the need for and delivery of medical and surgical treatment for this condition.”

“Within weeks of my arrival, referrals for patients began coming in, rapidly growing to over 20 per week. Within a few months, calls were coming in from across the province. One of the first patients I was called to see was a 41-year-old man weighing 436 kg, who had spent the last 9 months in an intensive care unit where he was being treated for intractable lymphedema and cellulitis of his lower extremities. The patient was living in his own ICU suite, while his caregivers were exploring the possibility of having him accepted for obesity surgery. It was already evident that this surgery could not be performed in Canada.”

“Within the first 6 months of my practice, I saw the heaviest people I had ever seen in my life. BMIs >50 kg/m2 were the rule rather than the exception. Most were below the age of 45, virtually none were currently employed, few had drug plans, and none had coverage for antiobesity medication. The majority had a history of childhood-onset obesity, all had significant co-morbidities including diabetes, reflux disease, sleep apnea, and debilitating back and knee pains.

All had significant histories of weight loss attempts, ranging from Weight Watchers and very low- calorie diets to rather questionable ‘medically supervised’ commercial weight loss programs. Many had also failed on pharmacotherapy. None had thus far been offered surgical treatment – the few who had tried to find surgeons in Canada soon discovered that there were only six surgeons performing obesity surgery in the province (population 9,000,000), none of whom were accepting referrals. Some patients were vaguely aware of a process for ‘out-of-province’ referrals, but none knew how to go about it or whom to ask for assistance.

Interestingly, despite the undeniable suffering and disability caused by their excess body weight, a seemingly large proportion of patients would not consider a surgical option because of the perceived risk. They were still hopeful that I would know of some magic bullet that could cure them of their condition (so were some of their referring physicians).”

“Clearly, surgery cannot be a solution for every patient with morbid obesity. Even with 1,000 operations a year, it would take over 200 years to operate on every morbidly obese patient in Ontario. So who should be operated upon, by whom, with what operation, and at what time point in the course of the disorder? Currently, there is little evidence from randomized controlled trials – the ‘gold standard’ of evidence-based medicine – on any of these issues. It appears that the basis for current practice is largely empirical, based on the expertise and judgement of individual surgeons. Yet, an important premise of ‘evidence-based’ medicine is to base care on the best available evidence. If empirical evidence is all we have, then this is what our standard of care should be based on – and no doubt, the empirical data in support of obesity surgery is impressive. It is clearly by far the most, if not the only, successful treatment for morbid obesity currently available.”

“Indeed, without the possibility of referring my patients to an experienced and dedicated obesity surgeon, I feel like I am practising nephrology with no access to dialysis or transplantation. There was only so much I could achieve with diet, blood pressure management, and immunosuppression in my patients with advanced renal failure. In the end, their survival depended on renal replacement therapy.

Similarly, there is only so much I can achieve with diet, exercise, and pharmacotherapy in my morbidly obese patients – ultimately resolution of their medical problems, if not their very survival, will depend on successful obesity surgery. In fact, from all that I have read and seen so far, obesity surgery for morbid (or should we call it malignant?) obesity appears far more successful in terms of improving quality of life, resolving co-morbidities, and promoting physical, mental, and socioeconomic rehabilitation than either hemodialysis or renal transplantation for patients with end-stage renal failure.”

“Surgery remains an important option for numerous ‘medical’ disorders: coronary bypass surgery for coronary artery disease, fundoplication for gastro-esophageal reflux, parathyroidectomy for hyper-parathyroidism, bullectomy for pulmonary bullous emphysema, knee replacements for osteoarthritis, kidney transplantation for renal failure, to name a few. Younger physicians perhaps forget that less than two decades ago, surgery was the treatment of choice for gastric and duodenal ulcers. All of these patients require long-term follow-up and management by internists or family physicians. Recognition of the important role of obesity surgery in the treatment of morbid obesity by internists and family physicians, and their commitment and dedication to the long-term medical management of patients who have undergone bariatric surgery, is long overdue.

For my part, I will undertake all that is necessary to establish bariatric surgery as an important and much needed surgical program at our university medical center.”

A lot has happened since I wrote these words.

Only days after I accepted my current position at the University of Alberta, the Ontario Government did announce funding for a bariatric program at McMaster – too late for me, I had already signed my new contract.

Today, Ontario does have its own Bariatric Network of “Pre-assessment” Clinics and bariatric Centres of Excellence. On the other hand, Ontario has yet to find a model that will appropriately look after the well over 2,000 patients who now receive bariatric surgery each year. There is still no non-surgical program that will treat obese patients early enough to prevent them from reaching a stage where they do need surgery. Nor is there a system in place to manage those who are not good candidates for or do not choose to undergo surgery.

Despite thousands of operations, there is still no real ‘academic’ bariatric program in Ontario – in 2010/11  there was barely a handful of peer-reviewed publications on bariatric care from all of Ontario – not even one paper per medical school – not surprising perhaps, given that there is not even a single chair in bariatric medicine or surgery at any of its five universities.

So, while more patients are now at least getting treatment, the field of bariatric medicine and surgery is still seeking form and structure in Ontario. To be fair, the situation is not that much better in other provinces.

Quebec has seen some improvements in access, but lags well behind Ontario in numbers. Nova Scotia has a fledgling program as does New Brunswick. Saskatchewan and Manitoba now perform a handful of surgeries a year. BC still has no recognizable bariatric strategy.

With about 600 surgeries performed across Alberta together with significant investments into a provincial obesity plan, Alberta, given the size of its population, may be slightly ahead of the pack – at least academically, it ranks number one, if the number of scientific publications on bariatric surgery is any indicator (12 paper in 2011, closely followed by Quebec with 10 articles, easily outranking all of Ontario with a single paper published in 2011).

Thus, eight years after I wrote this editorial, surprisingly little has changed when it comes to the recognition and importance of bariatric care and the need for greater investments and resources into researching the many open questions about the care of these patients.

Across Canada it is still far easier for someone with failing kidneys to receive dialysis than for someone with severe obesity to receive even minimally adequate medical or surgical treatment.

I wonder what the next eight years will bring to the field and to my patients – how much longer are they willing to wait?

Edmonton, Alberta