Treatment and management of obesity: is surgical intervention the answer?
|Abstract:||Obesity is rapidly becoming a major health concern and could be considered equal to smoking as a preventable cause of premature death. The National Institute for Health and Clinical Excellence (NICE 2006) estimated that 1.1 billion people are overweight, a number rivalling those who are underweight globally. Recent statistics for England from the National Health Service (NHS 2011) report that in 2009/10 there were 7,214 bariatric surgical procedures performed on people of varying ages.|
(Care and treatment)
Obesity (Health aspects)
|Publication:||Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589|
|Issue:||Date: April, 2012 Source Volume: 22 Source Issue: 4|
|Topic:||Event Code: 310 Science & research|
|Geographic:||Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom|
Obesity is damaging our nation's health, reducing quality of life (QOL), and ultimately leading some individuals to premature death. With over half the population known to be either overweight or obese, it is paramount to address obesity at its root cause (NICE 2006). The estimated annual cost to the NHS of obesity and overweight patients in England is between [pounds sterling]6.6 and [pounds sterling]7.4 billion (NICE 2006). This includes treatment and prevention of obesity and co-morbidities.
Obesity is an emerging global health epidemic. According to the Centre for Disease Control and Prevention (2010), obesity is rapidly spreading across regions and demographic groups internationally. An estimated 97 million adults in the USA are currently overweight or obese, representing more than 50% of the adult population, with approximately 11 million suffering severe obesity. The American Society for Metabolic and Bariatric Surgery (2010) reports that obese individuals have a 50-100% increased risk of death compared to adults with a normal recommended weight, which equates to between 300,000 and 587,000 deaths each year. This substantial increase in health risks has made obesity the second leading cause of preventable death in the USA (IFSO 2010). The NHS statistics (NHS 2011, p6) state that these figures are consistent with the UK reporting: 'In 2009, almost a quarter of adults (22% of men and 24% of women aged 16 or over) in England were classified as obese (BMI 30kg/m2 or over)'.
The ultimate aim of weight loss is to improve existing co-morbidities, or modify associated risks. The degree of obesity can be measured using tools such as the body mass index (BMI) which measures body fat based on height and weight (NHS 2010). Extreme obesity (BMI>40kg/m2) requires a multidisciplinary approach to assess individual treatment plans, and surgery has begun to play an increasing role (ASGBNI 2010).
Surgical intervention for weight loss includes three types of surgery: restrictive, malabsorptive, or a combination of both. Restrictive surgery limits food intake by creating a narrow passage from the upper part of the stomach into the lower part.
Malabsorptive surgery excludes most of the small intestine from the digestive tract so that fewer calories and nutrients are absorbed. Surgery for the treatment of obesity, generally termed bariatric surgery, has proved efficient in achieving weight loss and reducing co-morbidities in the majority of patients (NICE 2006). However, despite its success, it is not suitable for all patients; therefore, certain criteria must be met when considering patient selection for bariatric surgery.
Busetto et al (2005) concur that, in order for effective weight loss outcomes to be achieved, adequate psychological assessment must be undertaken. This is further supported by van Hout et al (2008) who suggest that early patient evaluation highlights psychological functioning and issues with personality and body image, which enables an informed decision to be made regarding the correct weight loss regime.
Opting for surgery as a treatment for obesity is a long-term commitment, and the decision must not be taken lightly. Ogden et al's (2006) study states that patients on the whole chose surgery through a lack of control, and a desire to hand over control to an external force. The preoperative and postoperative evaluation of these surgical treatments should therefore be based on both objective data, such as long term weight loss and co-morbidity improvements, and subjective data such as improved QOL. Folope et al (2008) reiterate this, concluding that bariatric surgery is not only effective in reducing and maintaining weight loss, it also significantly improves QOL for obese patients.
Improvement in QOL can be one of the most gratifying outcomes of bariatric surgery. A number of studies clearly demonstrate major QOL improvements following bariatric surgery (Folope et al 2008, Munoz et al 2007, Ogden et al 2006). However, the fundamental and perhaps most important task in addressing the obesity epidemic is prevention. Unfortunately, strategies that have been employed to date in an effort to prevent the development of obesity have been disappointing, and the problem of obesity has worsened (NICE 2006, WHO 2007).
There is no doubt that the obesity problems we face today are related to our modern western environment. We live in a world of plentiful and attractive energy dense foods, and a working and leisure environment that encourages sedentary behaviour. Solutions to the treatment and prevention of obesity will require involvement from multidisciplinary teams within our communities at many levels (NICE 2010a).
Literature search strategy
A clear and focused question was established using PICO (population/intervention/comparison/outco me) framework - see Table 1 (Nordenstrom 2007). The question was:
'Treatment and management of obesity: Is surgical intervention the answer?'
This framework assisted in the formulation of answerable clinical questions, breaking down the question into four key elements (Table 1). A systematic search of current literature was carried out covering the years from 2005 to present (Table 2). In addition to the electronic searches, hand searches of obesity-focused journals were undertaken. Initial searches were limited to papers published in the UK, followed by searches including Europe, USA and Australia to achieve global comparison.
Table 2 Search strategy
Advanced searches were made using database keyword headings as well as title abstract searches: surgery, overweight, diet regimes, weight, body mass index, revention, and exercise. Truncation symbols were used to locate plurals and any synonyms. However, these proved too broad, and were not considered relevant to he literature search.
The keywords were used to search the following databases: The Cochrane Library, PubMed, British Nursing Index, CINAHL 1981 to Present, MEDLINE 1950 to Present, EMBASE 1980 to Present
Policy and professional development literature was also searched focusing on key documents from the World Health Organisation (WHO), and NICE. A process of simple elimination then narrowed down these articles further utilising specific inclusion and exclusion criteria pertinent to the author's clinical practice setting (Table 3). Data from each paper was extracted and summarised, by evaluating the content utilising critiquing tools. Muir Gray (1997) recommends that using Critical Appraisal Skills Programme 'CASP' tools, will aid individuals with decision-making skills, and promote effective delivery of evidence-based-healthcare.
Table 3 Study inclusion/exclusion criteria
Study inclusion criteria
* Clinical trials comparing two different bariatric surgical procedures (vertical banded gastroplasty, or adjustable gastric banding)
* Studies comparing surgery with non-surgical management for obesity
* Studies comparing contemporary methods of weight loss (non-surgical)
* Studies involving adult human patients only
* Studies involving patients with a BMI greater than 30
* Studies undertaken for a minimum of 1 year, and a maximum of 10 years
Study exclusion criteria
* Non published literature
* Studies specific to one type of obesity related co-morbidity
* Studies undertaken for less than 1 year
Patient suitability for surgery
Obesity is not a new disease; it has been a major health concern for many years, with its prevalence increasing globally. Until fairly recently, surgery for the treatment of obesity on the NHS was not deemed an option for patients, but was considered as a last resort once non-surgical methods had been attempted and failed (NICE 2006). Bariatric surgery is now recommended as a treatment option for people with severe obesity when certain criteria are fulfilled (NICE 2006). NICE recommends that all appropriate 'non-surgical measures' have been tried previously, but have failed to achieve, or maintain, clinically beneficial weight loss for at least six months. Ogden et al's (2006) study inclusion criteria stipulated that patients enrolling on weight loss programmes were only offered surgical-intervention when all previous attempts at weight-loss had failed. Bariatric surgery is also recommended as a first-line option (instead of lifestyle interventions or drug treatment) for adults with a BMI of more than 50 kg/[m.sup.2] in whom surgical intervention is considered appropriate (NICE 2006) (Table 4).
Obesity and body mass index (BMI)
In order to assess the degree of obesity, it is important to use recommended universal measuring systems (WHO 2007). BMI is a measurement of body fat based on height (in metres), and weight (in kg) (Table 4). It applies to both adult men and women (NHS 2010) and is simplistic in its application. However, BMI does not differentiate between body fat and muscle mass. Therefore, BMI can be misleading in athletes who have low body fat percentage but are not overweight (NOF 2009) and should only be used as a general guide.
As BMI index is a calculation from weight and height alone, it assumes that the increase is due entirely to body fat. Equally, individuals with large stomachs, but thin arms and legs, fall beneath the threshold of obesity according to their BMI. Therefore, waist circumference also has limitations, especially in morbidly obese patients where it is inaccurate, and it does not take height into account (NOF 2009). It is also valuable for tracking improvements in a person who is maintaining their dietary input, but increasing physical activity, as their waist will shrink but their BMI may stay the same. In ethnic minority groups, especially people from southern India, a lower threshold of waist circumference may be utilised prior to surgery (WHO 2007).
The Association of Surgeons Great Britain and Northern Ireland (2010) state that there are many potential benefits of robustly commissioning an effective bariatric surgical service for the treatment of severe obesity. These include:
* achieving long-term weight loss
* decreasing overall mortality after surgery
* reducing the development of new co-morbid conditions
* reducing healthcare services after surgery.
This bariatric service should also result in improving clinical performance, and patient-centred care, through implementing the recommendations for bariatric surgery, to include specialist dietetic follow-up outlined in the NICE clinical guideline on obesity (NICE 2006).
Obesity and co-morbidities
Obesity is a chronic condition associated with increased risk of co-morbidities such as type II diabetes and cardiovascular disease (Table 5). Obesity can also create psychological and social burdens for patients, often resulting in social stigma, low self-esteem, reduced mobility and poorer QOL (NICE 2006). The NICE guidelines on obesity state that there is increasing recognition in the UK and globally, that there is currently an 'obesity epidemic'. The WHO (2007) estimates that, by 2012, more than 12 million adults and 1 million children in England will be obese if no action is taken to prevent and treat this epidemic.
Numerous unfavourable changes occur to a patient's health during periods of substantial weight loss, in particular in the metabolic syndrome and cardiovascular system. Significant weight loss should improve accepted parameters of cardiac function and cardio-vascular risk profiles (O'Brien et al 2006). McQuigg et al (2008) concur that obesity places significant risk on the cardiovascular system; highlighting how this risk is significantly reduced with 10% weight change. Batsis et al (2008) reinforces this suggesting that surgical intervention induces considerable improvements in metabolic syndrome, but is greatly dependent on the amounts of excess weight lost. Colquitt et al's (2009) systematic review clearly identifies how weight loss will lead to high rates of resolution of diseases like type II diabetes.
O'Brien et al's (2006) study compared 80 adult obese patients using a non-surgical control group versus a surgical group to measure changes in health and QOL. They compared weight-loss outcomes of surgical intervention with an intensive medical programme over a 24 month period. The study reported that bariatric surgery was clinically significant with regard to effective weight-loss, resolving metabolic syndrome, and improving patients QOL. The researchers concluded that modest weight loss, achieved through lifestyle change, reduced the number of people with impaired fasting glucose, often leading to the development of type II diabetes. However, this study was only undertaken for two years, with recommendations for further long term studies.
Colquitt et al (2009) assessed the effects of bariatric surgery treatment and management regimes, and their effects on weight loss, QOL, and co-morbidities. The study reported that significant weight loss could be associated with reduced co-morbidities such as diabetes and hypertension. The short-term results showed improvements in health-related QOL, although long-term effects were less conclusive. The study concluded that bariatric surgery achieved much greater weight loss results than conventional methods. Yet, most importantly, successful maintenance of weight loss was reported for at least ten years.
Obesity and quality of life
Bariatric surgery requires huge lifestyle changes on the part of the patient, as well as commitment to long-term follow-up. Busetto et al (2005) reported that when the morbidly obese patients within their study population were supported with adequate psychological treatment, this resulted in positive outcomes, both in QOL and sustained weight loss. Ogden et al's (2006) study explored how patients' QOL, feelings of self-worth and eating behaviours improved after weight-loss surgery, with significant improvements in confidence and body image. Some participants reported that they had an overall renewed sense of energy. Munoz et al (2007) undertook their study to ascertain why patients chose surgical intervention for the treatment of obesity. Their results showed that patients became motivated primarily to control current medical and health related issues, and not depressive symptoms. Yet a significant proportion of participants had endorsed psychological and improved QOL as important decision-making factors.
Psychological effects of obesity surgery
It is important to consider the patient's physiological wellbeing prior to the decision to operate, to determine whether bariatric surgery is appropriate for the individual. Possible predictors of good and poor weight loss outcomes, and compliance after surgery, would need to include observed weight loss and its effects on moods swings, eating behaviours, and cognitive attitude to diet regimes. Busetto et al. (2005) specifically focused on obese patients suffering from binge eating disorders (BED), and their need for psychological support. BED is characterised by compulsive ingestion of very large quantities of food, but without purging afterwards. The study concluded that obese patients diagnosed with BED had positive weight loss outcomes after bariatric surgery, as long as they had adequate psychological support. In contrast, some patients, possibly inadequately assessed for surgical intervention, could not comply with eating restrictions post surgery, and therefore demonstrated high frequency vomiting. These patients also required a higher frequency of gastric band adjustment in the initial stages after surgery.
van Hout et al (2007) summarised that many studies of psychological factors during the treatment of obesity have not produced consistent findings. During this particular study early psychological assessment and suitability for surgery was carried out preoperatively, and continued through to the two-year point. The study concludes that after bariatric surgery considerable weight loss was achieved, with significant changes in eating and lifestyle habits. However, the researchers did highlight how some improvements achieved by a small group of participants diminished overtime, with not all patients benefiting in the same way. van Hout et al (2008) conducted a further study which included assessment of body image and personality traits. The results showed that both weight loss and psychological functioning showed significant improvements, although depressive and sleeping problems varied. The most robust improvements were seen in body image, and how patients perceived themselves after surgery and successful weight loss. However, the results were not consistent across the study group.
Ronchi et al (2008) studied behavioural characteristics of severely obese patients seeking bariatric surgery. They found that this patient group were more psychologically compromised than obese patients with lower BMIs, and required enrolment on behaviour-modification programme to address individual issues around body image. Collazo-Clavell et al (2006) concurred that there is a need for full psychological assessment pre-operatively and follow-up support post-operatively. The researchers stated that this type of service prepares patients for lifestyle changes that are paramount for long-term weight loss success. They also discussed how some patients presented with long term histories of abuse and psychological disorders, and that these issues needed to be addressed in order for the surgical intervention to be successful.
In order to be able to acknowledge bariatric surgery as an ethical clinical treatment for obesity, the holistic patient assessment needs to include the management and long-term follow-up of weight loss regimes. Shay et al (2009) elucidate that, despite current research and guidelines on obesity, many primary care providers do not address weight or weight control strategies with patients. Reasons for this include time constraints, inadequate training and funding. An opportunity for clearly defining and standardising the criteria for those requiring subsequent plastic surgery is essential when assessing service demand for people requiring bariatric surgery, and specialist dietetic follow-up.
Wadden et al (2007) explore the issues of plastic surgery, or body contouring after bariatric surgery. These include breast reductions, abdominoplasty, and removal of excess skin to limbs. The researchers report that there is limited evidence to support the psychological effects of body contouring; this could be due to the relatively newness of bariatric surgery as a treatment for obesity. Highlighting the importance of reducing inequalities in healthcare systems will ensure that obese patients have access to multidisciplinary teams. This should ensure that bariatric services are appropriately integrated, and that clear referral pathways are in place so that bariatric surgery is provided alongside other clinical or public health weight management services.
The National Obesity Forum (NOF 2009) has designed an obesity care pathway to act as a guide during patient assessment. This includes identification and assessment of obesity and the various treatment and options available, patient monitoring and auditing of the patient's progress. Thus, increasing informed patient choice through the provision of information on a variety of procedures, allowing the patient and clinician jointly to decide on the best intervention based on the best available evidence. Folope et al (2008) supports this decision by stating that it would be un-ethical to conduct one specific surgical procedure without assessing patients as individuals, and taking into account the available resources at the time of surgery. Muir Gray (1997) reiterates this, highlighting the importance of involving patients in 'face-to-face' decision making, whereby the clinician and patient can discuss all the available options.
As the number of bariatric procedures increases, the number of patients with complications could rise. Tanner and Allen (2009) concur that there needs to be an opportunity to discuss the complications that could arise from bariatric surgery, and reiterate the importance of patient compliance post-surgery. The complications potentially include wound infection, deep vein thrombosis, and early bowel obstruction, to name but a few. This should ultimately result in a cost efficient service and assist providers of healthcare to manage their commissioning budgets more effectively (NICE 2010b).
Bariatric surgery and the NHS
The Royal College of Surgeons of England (RCS 2010) analysed that access to weight-loss surgery may be seen as inconsistent, unethical and completely dependent on geographical location. Current constraints on NHS funding mean that in some areas, NHS patients are being denied surgery. Greenhalgh (2006) suggested that expensive interventions, however successful long-term, may be withheld from patients for the simple reason of cost, or the fact that the patient was unable to demonstrate weight loss prior to surgery (NICE 2006). It is imperative that there is consistency and transparency across the NHS so that patients are treated equally. Ronchi et al (2008) commented on the fact that only a minority of obese patients in the Western World are able to undergo bariatric surgery. This is despite the fact that in Italy, unlike some other countries, social security covers the cost of bariatric surgery, and is not dependent on the patient's socioeconomic status. The criteria for surgery in the UK vary dramatically depending on the geographical location and the Strategic Health Authority (RCS 2010).
However, while some primary care trusts adhere to the guidelines, only patients with a BMI of 50 or 60, and with obesity related illness, are being referred for surgery (RCS 2010). Therefore, it is in the interests of morbidly obese patients that healthcare trusts work towards offering weight loss surgery, in accordance with NICE guidelines, as quickly as possible so that there is consistent and fair access to this treatment in England and Wales. NICE has also produced a commissioning guide to help health professionals in England to implement effective bariatric surgical services (NICE 2010c). These guidelines are currently core standards, and performance against these standards will be assessed by the Department of Health (2010).
Obesity and cost effectiveness
The RCS (2010) state that around one million people meet NICE criteria, with around 240,000 requesting surgery, yet only 4,300 NHS weight-loss operations were carried out in 2009. Consequently the delay in treating these patients is draining NHS resources, with obesity associated healthcare costs estimated at [pounds sterling]7.2billion per annum (RCS 2010).
Current evidence states that surgery is cost-effective in the majority of cases, with operating fees recouped within three years, resulting in obesity associated costs being eliminated (ASGBNI 2010). There may be a need for the Department of Health to invest in long term strategies to ensure that all patients have equal access to treatment delivered by experienced multi-disciplinary teams.
The NICE collaboration has been commissioned by the Department of Health to develop guidance on preventing obesity. It will include contributions from both local and community levels and will be published in 2012 (NICE 2010a). The Association of Upper Gastrointestinal Surgeons of Great Britain and Northern Ireland (2010) state that specialist bariatric teams will require properly equipped centers that can offer full assessment, an appropriate treatment regime, and provide safe long-term follow up and emergency re-admission.
NICE guidelines (2006) were designed to signal the end of postcode lotteries, yet some patients requiring surgical treatment are still being denied (RCS 2010). Therefore, it is necessary to recognise the difficulties faced in dealing with a 'new' disease of epidemic proportions. Powers et al (2007) summarise the medical effectiveness and cost-effectiveness of bariatric surgery stating that diet and exercise regimes are rarely successful at sustained weight-loss. The researchers conclude that denying obese patients assess to bariatric surgery is unjust, and does not make economic sense.
Obesity causes serious medical conditions that can result in death. The NHS is currently spending billions of pounds treating obesity and its related co-morbidities (Haslam et al 2009). NICE (2006) guidelines are clear that bariatric surgery is only for people who are severely overweight, who are already receiving treatment in specialist clinics, and who have tried other treatments to lose weight previously. The identification and characterisation of safe and effective treatments for obesity are no longer sufficient. The cost of the different available weight loss and weight management options needs to be evaluated. A major role is to provide education to the health profession at large regarding the identification of those at risk in our community, and in providing management strategies for the prevention and treatment of obesity related diseases (NICE 2010b).
Weight loss is known to be associated with improvement of intermediate risk factors for disease, suggesting that weight loss would also reduce mortality (Colquitt et al 2009). However, conclusive and controlled long-term interventional studies showing that weight loss actually reduces the risk of death, have been lacking as yet. Christou and Sampalis' (2004) retrospective cohort study involving obese patients, and Sjostrom at al's (2007) study involving obese patients with diabetes, both concluded that bariatric surgery may result in a marked reduction in mortality. Busetto et al (2005) supported this further by examining whether bariatric surgery was associated with lower mortality and postoperative complications. They concluded that complications were minimal, and were mainly either band-related, or port-related, and required careful monitoring postoperatively.
The use of bariatric surgery has increased dramatically during the past decade. Whether weight loss induced by bariatric surgery has favourable effects on a patient's life span long-term remains unclear. Bariatric surgery for severe obesity is associated with long-term weight loss and decreased overall mortality (Colquitt et al 2009). To ascertain conclusively the effects of global weight loss on mortality, additional trials are needed for a guideline review to be published in 2012 (NICE 2010a). O'Brien et al's (2006) study measured the weight-loss outcomes of surgical intervention compared with an intensive medical programme over a 24 month period. The study found that surgery was clinically significant in its effectiveness with weight-loss, resolving metabolic syndrome, and it also improved patients QOL.
Dixon and Dixon (2006) discussed how weight loss could be achieved in many different ways depending on the individual. Obviously the more weight-loss achieved, the greater the outcome for patients. The researchers placed the success with the management strategies in place, which was tailored for individuals. Dixon et al (2007) assessed the changes in body composition by comparing surgical intervention with a medical programme, with encouraging results towards the extensive and sustained weight loss achieved from the surgical group for the duration of the two year study. Although the medical programme showed good results initially, weight was gradually regained proving that on the whole, it was an unsuccessful method of weight loss. Shaw et al (2009) assessed the efficiency of exercise regimes as a means of achieving weight-loss in obese patients. However, the results proved disappointing regarding weight-loss, yet there were health benefits to the patients. In an attempt to combat obesity nationally, the WHO (2007) published guidelines using a population-based approach to reduce obesity, which included advice on diet and physical activity to promote health education and improve QOL.
Evidence suggests that surgical intervention is the best available treatment for obesity. However, a multidisciplinary weight-loss maintenance service is required for significant long-term weight loss to be achieved. Although the initial cost and time of setting up the service must be taken into account, the long-term benefits will outweigh these. It should be remembered that this treatment is not suitable for all patients, and it is by no means a quick fix solution to being overweight. The ultimate goal of bariatric surgery should not only be reducing weight and counteracting co-morbid conditions, but also improving psychological functioning. This may motivate patients to adhere to adequate health behaviour to maintain the surgically established weight loss long term.
This review enabled a thorough search of the available evidence through systematically reviewing various research studies surrounding the use of surgical intervention for obesity within given criteria. However, it is apparent that more long-term prospective studies are required to confirm the long-term benefits of bariatric surgery according to the type of surgical procedure. These studies must include psychosocial functioning and support, and measures of an improved quality of life for the patient.
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About the authors
PGCE, BSc (Hons), Dip He, ASP, ODP
Senior Lecturer, Allied Health & Medicine, Faculty of Health, Social Care & Education, Anglia Ruskin University
Sue Lord PG Dip, BA education, RGN, RNT, ASP
Head of Department, Allied Health & Medicine, Faculty of Health, Social Care & Education, Anglia Ruskin University
No competing interests declared
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Step Population 1. Population Obese patients 2. Intervention Bariatric surgical procedures 3. Comparison Conventional weight management regimes 4. Outcome Substantial weight loss and improved QOL Table 1 The PICO framework (Nordenstrom 2007)
Body mass index (BMI) (kg/m2) Category Underweight <18.5 Normal 18.5 - 24.9 Overweight 25.0 - 29.9 Obese class 1 > 30 Underweight 30 Severely obese class 2 > 35 Morbidly obese class 3 > 40 Super obese > 50 Table 4 Classification of adult obesity (NHS 2010, WHO 2007)
Diabetes, type 2 Osteoarthritis-knees, hips, feet Hypertension Low back pain Dyslipidemia Infertility Ischemic heart disease Polycystic ovary syndrome Stroke Obstetric complications Cardiomyopathy Foetal abnormalities Obesity-hypoventilation Venous thromboembolic disease syndrome Pulmonary hypertension Depression Asthma Cancer-breast, bowel, endometrium, prostate Obstructive sleep apnoea Venous/stasis ulcers Gallstones Accident-prone Non-alcoholic steatohepatitis Intracranial hypertension Urinary incontinence Gout Gastroesophageal reflux Skin-acanthosis nigricans, acne, interigo, hirsutism Table 5 Co morbidities of obesity (NICE 2006)
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