Search Results for "severe obesity"
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 »
Diet and Physical Activity Reduces Cardiometabolic Risk in Severe Obesity
One of the important indications for weight loss in people with excess weight is to reduce their risk for cardiometabolic complications. But, as regular readers of these pages are aware by now, diet and exercise may be of limited benefit, especially in individuals with severe obesity. So exactly how effective are such lifestyle interventions in this population? This question was now addressed in a randomised controlled trial by Bret Goodpaster from the University of Pittsburgh, PA, and colleagues in a paper recently published in JAMA. In order to determine the efficacy of a weight loss and physical activity intervention on the adverse health risks of severe obesity, 130 (37% African American) severely obese (class II or III) adult participants without diabetes were enrolled in a one-year intensive lifestyle intervention consisting of diet and physical activity. However, while one group was randomised to diet and physical activity for the entire 12 months, the other group had the identical dietary intervention but with physical activity starting after 6 months. A total of 101 (78%) subjects completed the 12-month follow-up assessments. At 6 months, the initial-activity group lost around 11 Kg whereas the delayed-activity group lost around 8 kg. At 12 months, the corresponding weight loss was around 12 and 10 Kg, respectively. Not unexpectedly, associated with this weight loss was a significant reduction in waist circumference, visceral abdominal fat, hepatic fat content, blood pressure, and insulin resistance were all reduced in both groups. While the study shows that diet and exercise alone (irrespective of whether or not exercise is added from the start or after 6 months of dietary weight loss) can lead to significant weight loss with improvement in cardiometabolic risk factors, the question of course remains whether or not these changes remain sustainable. As we know, most patients tend to regain weight over time and it is highly likely that weight regain will result in a worsening in cardiometabolic risk factors. Nevertheless, the study shows that even in individuals with severe obesity, clinically meaningful weight loss is possible with diet and exercise alone, that it probably does not matter too much whether or not exercise is started on day one of the program, and that this may well be a reasonable strategy for individuals who can manage to stick with these lifestyle changes over time. Obviously, whether such efforts are durable in the long term in a relevant number of… Read More »
Medical Costs For Severe Obesity Higher in The Rich?
Recently, I blogged about our observation that even in a publicly funded health care system, lower income patients are less likely to receive bariatric surgery than folks with higher income. A new study by Thomas von Lengerke and colleagues from the University of Hannover, Germany, published in Psychosomatic Medicine, looks at the impact of socioeconomic status (SES) on direct medical costs for severe obesity in Germany (which has a mixed private and public insurance based health care system). The researchers compared the costs of severe obesity among German adults in a subsample (N=947) of the KORA-Survey S4 1999/2001 (a cross-sectional health survey in the Augsburg region, Germany; age group: 25-74 years). Data included visits to physicians, inpatient days in hospital, and received and purchased medication. Body mass index was measured and SES was determined via reports of education, income, and occupational status from computer-assisted personal interviews. In contrast to what the researchers expected (given the propensity for lower-SES patients to be heavier and have more medical problems), the excess costs of severe obesity were substantially (almost three-fold) higher in respondents with high SES (plus euro 2,966 vs. plus euro 1,012). The differences were even greater after adjustment for the Physical Functional Comorbidity Index (PFCI), with severe obesity’s excess costs being euro 2,406 in the high SES-Index group versus only euro 539 in the lower status group. This study confirms our findings (using the example of bariatric surgery) that despite similar or greater obesity burden, lower SES patients are less likely to incur direct health costs related to severe obesity. Several factors may explain these findings: 1) Poorer patients may be less likely to recognize severe obesity as a medical condition that requires medical and/or surgical treatment. 2) Health services may be less accessible to lower SES patients for monetary reasons such as transportation to doctor/clinics, parking, taking time off work, etc. 3) Lower SES patients may be more prone to weight-bias and discrimination thereby making them less likely to seek out and insist on receiving the same level of health care as better-off patients. Whatever the reasons, it appears that social inequality in access to obesity treatments and equitable allocation of health care resources across the SES continuum is an issue that is not just limited to Canada. I’d love to hear what my readers think are the likely causes of this disparity and any suggestions that may help address… Read More »
Gene Deletions May Lead to Severe Obesity
While there is no doubt that our current obesogenic environment is the major driver of the obesity epidemic there is also no doubt that these environmental factors don’t affect everyone to the same degree. Indeed, there is now largely consensus amongst experts that the question of who will get obese and who won’t, given that we are all more or less exposed to the same environmental pressures, is largely determined by our genetic make up (yes, genes also influence behaviour!). This is even more true for those individuals who make up the rapidly growing group of people with severe obesity – anyone, who believes that you can get to weighing over 350 lbs or more simply by making wrong “choices” probably also still believes in Santa Claus and can’t wait for the Easter Bunny. Yesterday, the journal Nature reported another study that shows how genetic mutations can markedly increase the risk for severe obesity. In this large multicentre study headed by my friend and colleague Philippe Froguel, the investigators found a highly penetrant form of obesity, initially observed in 31 subjects who were heterozygous for deletions of a surprisingly large area of chromosome 16 (593 kilobases at 16p11.2) and who also presented with some cognitive deficits. Subsequently, they identified 19 similar deletions in genome wide association data in 16,053 individuals from eight European cohorts. None of these deletions were found in healthy non-obese controls and were estimated to account for 0.7% of the morbid obesity cases in the dataset. Interestingly, the parents of some of these index cases also had this deletion and were likewise obese. The cases with the deletion tended to be born with a normal weight but then became overweight at childhood and severely obese as adults. Unfortunately, this large stretch of chromosome 16 contains many different genes (as many as 30) and it is not clear from these studies exactly which or how these missing genes contribute to the severe obesity phenotype. Nevertheless, given that this is neither the first genetic defect to be associated with severe obesity nor likely to be the last one of what is believed to be a relatively large number of genetic mutations that have yet to be found, this report should come as a strong warning to anyone who believes that severe obesity is solely a self-inflicted condition resulting purely from poor “choices”. AMS Copenhagen, Denmark
