Rehabilitation Research in Severe Obesity

Severe obesity, an increasingly common condition, is posing an important challenge not just for patients with this disease but also for health professionals attempting to provide the best possible care for this population.

From doors not wide enough for oversized wheelchairs to limited weight capacity of diagnostic equipment, patients with severe obesity face a wide range of important obstacles to accessing and benefiting from urgently needed health care.

We recently examined this in an article published in the Journal of Advanced Nursing, in which we reported on the need for specialized equipment and staff education to ensure adequate management of obese patients in the emergency department.

Yesterday, I attended a full-day invitation-only Think Thank on Bariatric Rehabilitation co-hosted by the Canadian Obesity Network, the University of Alberta School for Rehabilitation and Capital Health held at the TELUS Centre for Professional Development, Edmonton.

The meeting was attended by over 50 participants including University of Alberta researchers from a wide range of areas including occupational therapy, physiotherapy, rehabilitation medicine, nursing, biomechanical engineering, mechanical engineering, civil and environmental engineering, physical education, and other relevant areas.

On the Capital Health side there were several high-level administrators responsible for acute care, long-term care and community care services as well as front line health professionals from various regional hospitals and health regions.

Other stakeholders included the Canadian Association of Occupational Therapists, Emergency Medical Services as well as suppliers for bariatric equipment.

It was clear to all that there is a wide knowledge gap regarding providing the proper medical care and rehabilitative services to patients with severe obesity and that the range of challenges to the healthcare system and particularly to front-line health professionals are largely unrecognized and unstudied.

There was a consensus that bariatric rehabilitation should be high on the research agenda of various faculties within the University of Alberta and could build on many strengths in rehabilitation services that already exist within the Capital Health Region and Alberta.

I learnt a lot and look forward to working with all attendees to develop a detailed research agenda to better understand the needs and find solutions to this important but largely invisible problem.

Edmonton, Alberta


IFSO Guidelines for Bariatric Centres

The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), at its Council Meeting in Porto, Portugal, September 2007, approved new guidelines for Bariatric Surgical Centres.

This not only reflects the global interest in this rapidly growing field of bariatric care, but also the need for guidelines that ensure at least a minimum standard of care for patients undergoing surgery for severe obesity.

The summary document, authored by John Melissas, IFSO President (2006-2007) and Head of the Bariatric Unit, at the University Hospital Heraklion, Greece, appears in this month’s issue of OBESITY SURGERY.

While most of the recommendations make good sense – this document, not surprisingly, provides a view from the surgical perspective rather than providing a framework for overall bariatric care. There is no doubt that currently the surgeons have the upper hand in this discussion, given that the data increasingly supports the role of surgery as the most effective (if not only) treatment for severe obesity.

However, as I have blogged before, obesity surgery is not just about surgery!

The following are my comments on some of the IFSO recommendations:

“Ensure that individuals who provide services in the bariatric surgery program are adequately qualified to provide such services.”

Fully agree, and would probably extend this recommendation to ANYONE dealing with bariatric patients – surgery or no surgery.

“Provide ancillary services such as specialized nursing care, dietary instruction, counseling, and psychological assistance if and when needed.”

Another “no-brainer” – again, not only should these ancillary services be available, but health providers in these services should all have undergone basic training in bariatric care including sensitivity training and have at least a basic understanding of the nature of severe obesity, its complications and treatment.

“Have readily available consultants in cardiology, pulmonology, psychiatry, and rehabilitation with previous experience in treating bariatric surgery patients.”

I would add to the list general internists, endocrinologists, gastroenterologists, intensivists, hospitalists, pharmacists and perhaps a few other specialities.

“Ensure that basic equipment necessary for the obese patients such as scales, operating room tables, instruments, and supplies specifically designed for bariatric laparoscopic and open surgery, laparoscopic towers, wheelchairs, various other articles of furniture, and lifts that can accommodate stretchers are available, as well as a recovery room capable of providing critical care to morbidly obese patients and an intensive care unit with similar capacity.”

This should be an essential requirement for ANY hospital regularly admitting severely obese patients – unfortunately, this is now the case in virtually every hospital in the Western World.

“Have the complete line of necessary equipment, instruments, items of furniture, wheel chairs, operating room tables, beds, radiology facilities such as CT scan and other facilities specially designed and suitable for morbidly and super obese patients.”

Same as above – should probably have such lists available in every hospital or medical facility in Canada.

“Have experienced interventional radiologists available to take over the non- surgical management of possible anastomotic leaks and strictures.”

Good one! Sometimes these would be interventional gastroenterologists. As often some of these services can be urgently needed, it may not be enough to train only one individual to deal with these issues (travel, vacation, etc.). Obviously, radiology facilities for bariatric patients would be essential (see above).

“Has supervised support groups for bariatric patients.”

I agree, support groups can be most helpful for these patients – but they do need supervision to not take off on “tangents”.

“Provides lifetime follow-up for the majority and not less than 75% of all bariatric surgical patients.”

Obviously, patients with bariatric surgery require life-long follow up – I only do not think that this is best done by the surgeon or “surgical” centres – in fact issues in follow-up are rarely surgical.

They are more often related to nutrition, rehabilitation and psychosocial issues that can ultimately determine outcome. Ideally counseling for these problems would be provided by primary care providers, who are adequately trained in looking after these patients – it is after all not “rocket science” – the majority of patients (if correctly selected prior to surgery) will probably do well with nutritional monitoring, regular lab work and access to psychosocial services as the need arises – all the job of primary care, not that of a surgeon.

Overall the IFSO recommendations are sensible and will hopefully be adopted by policy makers and health authorities in most countries, including Canada. Personally though, I prefer the route taken by the Canadian Association of Bariatric Physicians and Surgeons (CABPS), which ensures that ALL treatment options, both surgical and non-surgical find their place in the management of these complex patients – it is unlikely that surgeons will always provide the best “non-surgical” advise to their patients.

Obesity is indeed an ideal ground for fostering interprofessional practice.

Edmonton, Alberta