tag:theconversation.com,2011:/us/topics/bariatric-surgery-1201/articlesBariatric surgery – The Conversation2023-07-23T12:37:43Ztag:theconversation.com,2011:article/2091212023-07-23T12:37:43Z2023-07-23T12:37:43ZThe obesity epidemic is fuelled by biology, not lack of willpower<figure><img src="https://images.theconversation.com/files/538592/original/file-20230720-27-qvsftl.jpg?ixlib=rb-1.1.0&rect=222%2C138%2C4711%2C3107&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">For many people, trying to lose excess fat is very difficult without help. Effective treatment is available when obesity affects health.
</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/the-obesity-epidemic-is-fuelled-by-biology-not-lack-of-willpower" width="100%" height="400"></iframe>
<p>Since the time a human first used a tool to make life easier, increased weight has been inevitable.</p>
<p>From that day the amazing and rapid progress of human achievement has been on a parallel trajectory with the growing availability of calories and the health and social consequences — initially positive — that have come with it.</p>
<p>Through most of human history, <a href="https://doi.org/10.1146%2Fannurev-nutr-080508-141048">our species has had to cope with food scarcity</a>. Scrounging enough calories to stay alive was a struggle, and our ability to compete and survive sometimes meant enduring long breaks between scarce meals.</p>
<p>When food was abundant, our bodies stored excess energy in the form of fat to draw upon when food was not available.</p>
<h2>Ancient metabolism in a modern world</h2>
<p>Human ingenuity allowed our predecessors to harness fire, create weapons for hunting and invent farming. Our brains enabled our species to develop an easier, more comfortable life and a steady supply of food to support population growth.</p>
<p>As human progress continued, our ancestors learned to domesticate and use animals. Later, they invented machines to move ourselves and our belongings from place to place, and life became even easier.</p>
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<img alt="evolution silhouettes beginning with an ape, morphing into humans carrying fire or spears, and eventually to person pushing a grocery cart" src="https://images.theconversation.com/files/538774/original/file-20230721-23892-afrwop.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/538774/original/file-20230721-23892-afrwop.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=282&fit=crop&dpr=1 600w, https://images.theconversation.com/files/538774/original/file-20230721-23892-afrwop.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=282&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/538774/original/file-20230721-23892-afrwop.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=282&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/538774/original/file-20230721-23892-afrwop.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=355&fit=crop&dpr=1 754w, https://images.theconversation.com/files/538774/original/file-20230721-23892-afrwop.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=355&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/538774/original/file-20230721-23892-afrwop.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=355&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Our metabolism remains calibrated for a hard, uncomfortable life where every bite had to be earned through strenuous physical effort, and our brains are still telling us to eat more than we need.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>Today, mountains of calorie-rich (and often nutritionally poor) food and lakes of sugary beverages are readily available in much of the world. It’s no longer necessary to leave home — or even stand up — to access this cornucopia.</p>
<p><a href="https://obesitycanada.ca/guidelines/science/">Our biology has not yet caught up to our progress</a>, though. Our metabolism remains calibrated for a hard, uncomfortable life where every bite had to be earned through strenuous physical effort, and our brains are still telling us to eat more than we need.</p>
<p><a href="https://doi.org/10.2174%2F138920211795677895">Polygenic obesity — the inherited predisposition to consume and store calories</a> — is the inevitable outcome of our primal instincts colliding with amazing, man-made abundance. It’s also what makes it so hard to lose excess fat and keep it off.</p>
<h2>The brain’s role in obesity</h2>
<p>From our clinical work and our research in obesity we know that while some people can carry extra weight and be truly healthy, others suffer serious health consequences, <a href="https://doi.org/10.3390/ijms20092358">including diabetes, high blood pressure, cancer and arthritis.</a>
For far too long society has treated obesity as a personal failing while in reality it’s a <a href="https://obesitycanada.ca/guidelines/science/">biological, physiological, environmental, chronic disease</a>.</p>
<p>The fact is that for many, trying to lose excess fat is very difficult without help. The brain wants us to eat as much as we can because it thinks it’s helping us survive, and it has the power to overwhelm our best intentions. </p>
<p>Despite the prevalent view that people with large bodies should <a href="https://theconversation.com/its-time-to-bust-the-calories-in-calories-out-weight-loss-myth-199092">simply eat less and move more</a>, it’s nearly impossible to fight our genetic heritage or other factors that are not within our control. </p>
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<img alt="A chalk drawing of a brain, half of which is filled in with different types of food" src="https://images.theconversation.com/files/538591/original/file-20230720-25-6r6648.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/538591/original/file-20230720-25-6r6648.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=278&fit=crop&dpr=1 600w, https://images.theconversation.com/files/538591/original/file-20230720-25-6r6648.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=278&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/538591/original/file-20230720-25-6r6648.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=278&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/538591/original/file-20230720-25-6r6648.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=349&fit=crop&dpr=1 754w, https://images.theconversation.com/files/538591/original/file-20230720-25-6r6648.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=349&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/538591/original/file-20230720-25-6r6648.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=349&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The brain wants us to eat as much as we can because it thinks it’s helping us survive, and it has the power to overwhelm our best intentions.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>Our body defends its weight vigorously. It changes levels of leptin and insulin, which regulate appetite. <a href="https://obesitycanada.ca/guidelines/science/">Whenever we lose weight by restricting calories, hormones compel our brains to signal increased hunger and decreased fullness and they slow our metabolism in an effort to retain body fat</a>.</p>
<p>This makes it difficult to reduce weight and keep it off through diet and exercise alone. </p>
<p>In the meantime, another part of our brain, which regulates reward and pleasure, is also working to make us eat more. </p>
<p>The pleasure of eating food is <a href="https://doi.org/10.1016%2Fj.neuron.2011.02.016">driven by naturally occurring neurochemicals like dopamine, opioids and cannabinoids</a>, to help with survival and energy storage. People living with obesity may have a genetic predisposition toward a heightened reward system associated with food. Glossy packaging, aggressive marketing (<a href="https://www.apa.org/topics/obesity/food-advertising-children">often targeting children</a>), delicious but nutrient-poor foods, drive-through windows and online delivery services all enable this. </p>
<h2>Effective treatment</h2>
<p>Just as human progress brought us problematic obesity, it may also help resolve it. </p>
<p>That begins with accepting that <a href="https://obesitycanada.ca/guidelines/weightbias/">polygenic obesity is a disease and not a matter of willpower</a>. Rather than blaming and shaming one another for our size, we should be more understanding and educate ourselves about obesity, to help take stigma and judgment out of the equation.
<a href="https://doi.org/10.2105%2FAJPH.2009.159491">Society sends damaging messages about weight, especially through popular culture</a>, so we want to make this very clear: our weight doesn’t define who we are, and it does not define how healthy we are.</p>
<p>It’s important to recognize that when obesity does impair one’s health, it needs treatment, and effective treatment is available. <a href="https://doi.org/10.1503/cmaj.191707">Canada’s 2020 clinical practice guidelines</a> are based on three pillars: bariatric surgery, medication and cognitive psychotherapy. </p>
<p>Psychotherapy is critical to the effectiveness of surgery or medication, or both. Behavioural therapy can resolve questions such as: Why am I eating the way I do? What is my relationship with food? Where did that come from?</p>
<p>These pillars are the primary interventions that have been shown repeatedly to be able to help people with obesity improve their health while reducing their weight and keeping it off in the long run.</p>
<p>We need less judgment and more science. Progress is possible if we work for it.</p><img src="https://counter.theconversation.com/content/209121/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Megha Poddar is the Medical Director of the Medical Weight Management Centre of Canada. She has participated in the development and delivery of continued medical education with pharmaceutical companies who have obesity medications including Novo Nordisk and Eli Lilly. </span></em></p><p class="fine-print"><em><span>Sean Wharton is the medical director of The Wharton Medical Clinic and the lead authour of the Canadian Obesity Guidelines.
He has received funding from CIHR, Mitacs, Novo Nordisk, Bausch Health Canada Inc., Eli Lilly, and Boehringer Ingelheim. </span></em></p>Despite the prevalent view that people with large bodies should simply eat less and move more, it’s nearly impossible to fight our genetic heritage or other factors that are not within our control.Megha Poddar, Assistant (Adjunct) professor, Deptartment of Internal Medicine, McMaster UniversitySean Wharton, Adjunct professor, Department of Medicine, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1841532022-10-17T03:06:44Z2022-10-17T03:06:44ZThinking about bariatric surgery for weight loss? Here’s what to consider<figure><img src="https://images.theconversation.com/files/474467/original/file-20220718-16-y2eczw.JPG?ixlib=rb-1.1.0&rect=50%2C543%2C6659%2C3923&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.worldobesity.org/resources/image-bank/image-bank-search-results/man-working-from-home-2">World Obesity Federation</a></span></figcaption></figure><p>Bariatric surgery is weight-loss surgery to <a href="https://www.healthdirect.gov.au/guide-to-bariatric-surgery#what-is">treat obesity</a> or reduce weight-related health complications. These surgeries alter the structure of the digestive tract, which <a href="https://pubmed.ncbi.nlm.nih.gov/33249084/">helps reduce hunger</a>. </p>
<p>As dietitians and a bariatric medicine doctor, we often get asked when an adult might consider surgery for weight management.</p>
<p>The short answer is people may be eligible for surgery if they have a body mass index (BMI) over 40 (defined as severe obesity), or if their BMI is less than 40 but they have medical complications such as diabetes. </p>
<p>But bariatric surgery is <a href="https://www.cmaj.ca/content/192/31/E875">not suitable</a> for everyone with obesity. Here are some factors to consider if you’re thinking about it.</p>
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<h2>How is your weight impacting your health?</h2>
<p>The <a href="https://pubmed.ncbi.nlm.nih.gov/21838602/">Edmonton Obesity Staging System</a> is used to classify the physical, medical and wellbeing impairment of people with obesity. Stage zero means no impairment, while stage four – the highest category – indicates severe impairment. </p>
<p>People in <a href="https://pubmed.ncbi.nlm.nih.gov/32812345/">stages three and four</a> commonly have major health issues, higher medication and health service use, need <a href="https://pubmed.ncbi.nlm.nih.gov/26060580/">longer periods of treatment</a> to achieve their weight-related goals and are <a href="https://pubmed.ncbi.nlm.nih.gov/32812345/">at greater risk of complications</a> following surgery. </p>
<p>People eligible for bariatric surgery will typically be in stage three or four. </p>
<h2>How does bariatric surgery work?</h2>
<p><a href="https://asmbs.org/patients/bariatric-surgery-procedures">Bariatric surgery procedures</a> reduce stomach volume. Most are <a href="https://asmbs.org/patients/bariatric-surgery-procedures">keyhole procedures</a>, where small cuts are made in the abdomen and tiny cameras inserted to guide the operation. </p>
<p>Bariatric surgery makes people feel fuller. Combined with changes in dietary intake, it typically leads to long-term weight reduction of <a href="https://obesitycanada.ca/guidelines/surgeryoptions/">20% to 40%</a> of the person’s starting weight. </p>
<p>This weight loss <a href="https://pubmed.ncbi.nlm.nih.gov/32722673/">can help improve</a> high blood pressure, <a href="https://pubmed.ncbi.nlm.nih.gov/28801703/">type 2 diabetes</a>, sleep apnoea and fatty liver disease. </p>
<p>However, there are <a href="https://obesitycanada.ca/wp-content/uploads/2021/05/13-Bariatric-Surgery-Surgical-Options-and-Outcomes-v6-with-links.pdf">risks from surgery</a> which also need to be considered, including vomiting, constipation, increased bowel movements, as well as longer-term risks such as reflux, hernia, malnutrition and small bowel obstruction. </p>
<h2>Alternative approaches to weight management</h2>
<p>Before considering surgery it’s important to talk to a GP or obesity specialist about all suitable evidence-based approaches to improve your weight-related health, including <a href="https://theconversation.com/what-are-fasting-diets-and-do-they-help-you-lose-weight-76644">very low energy diets</a>.</p>
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<img alt="Woman runs on a path" src="https://images.theconversation.com/files/489909/original/file-20221016-17-tyarv7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/489909/original/file-20221016-17-tyarv7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/489909/original/file-20221016-17-tyarv7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/489909/original/file-20221016-17-tyarv7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/489909/original/file-20221016-17-tyarv7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/489909/original/file-20221016-17-tyarv7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/489909/original/file-20221016-17-tyarv7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Some people might reach their health goals through lifestyle changes.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/running-woman-end-thin-on-road-2012360633">Shutterstock</a></span>
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<p>Specific medications approved <a href="https://www.racgp.org.au/afp/2017/july/pharmacotherapy-for-obesity">for weight management in Australia</a> are available but can be costly. Medication can help achieve a 5-10% weight reduction, although results and <a href="https://www.racgp.org.au/afp/2017/july/pharmacotherapy-for-obesity">side-effects</a> vary, so regular review is needed. </p>
<p>While people with moderate obesity may lose enough weight to improve their health through <a href="https://obesitycanada.ca/guidelines/nutrition/">diet</a> alone, for severe obesity, diet may not be enough. </p>
<p>Weight management is a lifelong journey, so over time, <a href="https://www.cmaj.ca/content/192/31/E875">a person might try numerous approaches</a> and review their progress towards their goals at each stage. This includes interventions to improve nutrition, physical activity, fitness, mental health, and/or medications for health risk factors, appetite and complications from carrying excess body weight. </p>
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Read more:
<a href="https://theconversation.com/health-check-whats-the-best-diet-for-weight-loss-21557">Health Check: what's the best diet for weight loss?</a>
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<h2>A word about stigma</h2>
<p><a href="https://www.obesityaustralia.org/weight-stigma">Weight stigma</a> and bias are negative attitudes, beliefs or discrimination based on a person’s weight. This can occur in both public and private health settings and prevent people getting the medical care and support to improve their weight-related health. </p>
<p>It’s important for people to find a doctor they can work with to develop a comprehensive management strategy for them. That plan may, or may not, include bariatric surgery.</p>
<p>Weight stigma can also prompt people to discontinue health care after surgery because they feel bad, or are made to feel bad, about <a href="https://link.springer.com/article/10.1007/s11695-022-05908-1">their weight or surgical results</a>.</p>
<h2>When should bariatric surgery be considered?</h2>
<p>Access to bariatric surgery through public hospitals in Australia is currently <a href="https://insightplus.mja.com.au/2021/10/bariatric-surgery-public-system-access-still-terrible/">very limited</a>, unless you have private health insurance that covers bariatric procedures. </p>
<p>Other considerations are:</p>
<p><strong>1) What weight-related outcomes are you hoping for?</strong></p>
<p>From improved health to fewer medications, remission of type 2 diabetes or better physical mobility, having a clear understanding of potential positive post-surgery impacts helps with monitoring progress. </p>
<p>It also helps decide whether other approaches could be tried first, such as medications. </p>
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<img alt="Friends share a drink" src="https://images.theconversation.com/files/489518/original/file-20221013-24-76j86z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/489518/original/file-20221013-24-76j86z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/489518/original/file-20221013-24-76j86z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/489518/original/file-20221013-24-76j86z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/489518/original/file-20221013-24-76j86z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/489518/original/file-20221013-24-76j86z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/489518/original/file-20221013-24-76j86z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">It’s important to think about your own potential risks and benefits.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/itAjRl5ykq8">Unsplash/Allgo</a></span>
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<p><strong>2) What are advantages and disadvantages of bariatric surgery?</strong></p>
<p>Bariatric surgery has both <a href="https://pubmed.ncbi.nlm.nih.gov/35371868/">positive</a> and negative implications. While <a href="https://pubmed.ncbi.nlm.nih.gov/29900655/">body dysmorphia</a> (negative feelings about your body) can improve post-surgery, it might not. </p>
<p>Other common concerns which you should be prepared for include difficulty eating out with friends, potential <a href="https://pubmed.ncbi.nlm.nih.gov/33675022/">hair loss</a>, excess skin, bone and muscle loss. Special considerations may be needed for those planning <a href="https://pubmed.ncbi.nlm.nih.gov/31837948/">future pregnancy</a> to ensure they’re getting enough nutrients.</p>
<p><strong>3) Can the person considering surgery give fully informed consent?</strong></p>
<p>A “yes” means the person has had all their questions answered, fully understands that permanent weight loss is not guaranteed and that lifelong follow-up is needed to optimise their health. </p>
<p>While most people do lose substantial amounts of weight, weight can rebound <a href="https://link.springer.com/article/10.1007/s00464-021-08329-w">depending on</a> the type of and time since surgery, presence of emotional or disordered eating, and consumption of larger food portions. </p>
<p><strong>4) Can you access adequate post-operative support?</strong></p>
<p>The first year after surgery requires more intensive follow-up involving surgeons, GPs, obesity specialists and allied health providers. <a href="https://pubmed.ncbi.nlm.nih.gov/29465932/">Ongoing follow-up helps</a> to monitor health improvements, nutritional status, mental health and any weight regain.</p>
<p>Bariatric surgery may be the right choice for people with obesity where the benefits are clear, the time is right, and to optimise their health and wellbeing. But preparation and long-term support are important. The best place to start is to talk to your GP. </p>
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Read more:
<a href="https://theconversation.com/five-supplements-that-claim-to-speed-up-weight-loss-and-what-the-science-says-89856">Five supplements that claim to speed up weight loss – and what the science says</a>
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<img src="https://counter.theconversation.com/content/184153/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Clare Collins is a Laureate Professor in Nutrition and Dietetics at the University of Newcastle, NSW and a Director of the Food and Nutrition Research Program, Hunter Medical Research Institute (HMRI). She is a National Health and Medical Research Council (NHMRC) Leadership Fellow and has received research grants from NHMRC, ARC, MRFF, HMRI, Diabetes Australia, Heart Foundation, Bill and Melinda Gates Foundation, nib foundation, Rijk Zwaan Australia, WA Dept. Health, Meat and Livestock Australia, and Greater Charitable Foundation. She has consulted to SHINE Australia, Novo Nordisk, Quality Bakers, the Sax Institute, Dietitians Australia and the ABC. She was a team member conducting systematic reviews to inform the 2013 Australian Dietary Guidelines update and the Heart Foundation evidence reviews on meat and dietary patterns.</span></em></p><p class="fine-print"><em><span>Kathryn Williams is an Endocrinologist, the Head of Department of Endocrinology at Nepean Hospital and the Clinical Lead and Manager of the Nepean Blue Mountains Family Metabolic Health Service, a tertiary lifespan obesity service, in Greater Western Sydney. She is also a Conjoint Senior Lecturer at The University of Sydney. She has previously received funding from NovoNordisk, Pfizer and Lilly for clinical trials, development of educational materials and expert opinion.</span></em></p><p class="fine-print"><em><span>Tracy Burrows is a Professor in Nutrition and Dietetics at The University of Newcastle. She currently receives funding from the National Health and Medical Research Council from the Emerging leader investigator grant scheme (EL2), The National Heart Foundation and NIB Foundation. </span></em></p>It’s important to think about the weight-related outcomes are you’re hoping for and what other approaches could be tried first.Clare Collins, Laureate Professor in Nutrition and Dietetics, University of NewcastleKathryn Helen Williams, Conjoint senior lecturer, University of SydneyTracy Burrows, Professor Nutrition and Dietetics, University of NewcastleLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1293172020-01-27T12:20:03Z2020-01-27T12:20:03ZObesity, second to smoking as the most preventable cause of US deaths, needs new approaches<figure><img src="https://images.theconversation.com/files/310518/original/file-20200116-181593-akwlnw.jpg?ixlib=rb-1.1.0&rect=26%2C13%2C4394%2C3148&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Social campaigns to address the obesity crisis in America are failing. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/diet-change-healthy-lifestyle-concept-having-277748333">Lightspring/Shutterstock.com</a></span></figcaption></figure><p>The opioid crisis and deaths related to e-cigarette use among teenagers have dominated news headlines recently. Recently, the Centers for Disease Control and Prevention reported that 34 people had died as a result of vaping and, in 2017, opioid addiction was responsible <a href="https://www.cdc.gov/drugoverdose/data/statedeaths.html">for more than 47,000 deaths</a> in the U.S. Opioid addiction has been declared a <a href="https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Ongoing-emergencies">public health emergency</a>. </p>
<p>Yet these serious public health threats obscure an ever-present and growing calamity of obesity in the United States. Obesity is second only to cigarette smoking as a <a href="https://www.commonwealthfund.org/blog/2018/rising-obesity-united-states-public-health-crisis">leading preventable death</a> in the U.S. Nearly <a href="https://www.mailman.columbia.edu/public-health-now/news/obesity-kills-more-americans-previously-thought">one in five deaths of African Americans and Caucasians age 40 to 85</a> is attributed to obesity, a rate that is increasing across generations. </p>
<p>Clearly society needs better strategies to address this public health emergency. As a <a href="https://scholar.google.com/citations?user=E3XmWfEAAAAJ&hl=en">health economist</a> who has spent decades studying ways to prevent disease, I believe there are some policy options that could help.</p>
<h2>The American obesity crisis</h2>
<p><a href="https://www.cdc.gov/obesity/adult/causes.html">Many factors contribute to obesity</a>, including genetics, diet, physical inactivity, medications, lack of education and food marketing. </p>
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<img alt="" src="https://images.theconversation.com/files/311485/original/file-20200123-32164-3zl0lr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/311485/original/file-20200123-32164-3zl0lr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=434&fit=crop&dpr=1 600w, https://images.theconversation.com/files/311485/original/file-20200123-32164-3zl0lr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=434&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/311485/original/file-20200123-32164-3zl0lr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=434&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/311485/original/file-20200123-32164-3zl0lr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=545&fit=crop&dpr=1 754w, https://images.theconversation.com/files/311485/original/file-20200123-32164-3zl0lr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=545&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/311485/original/file-20200123-32164-3zl0lr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=545&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The volume of food consumed contributes to weight gain.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Go-For-the-Food-Cincinnati/ef8097858c154e5aa856fc9b36059d8a/13/0">Al Behrman/APimages.com</a></span>
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<p>People who are obese face heightened risk for diabetes, heart disease, stroke, high blood pressure and certain types of cancers, among other conditions. The estimated annual medical cost of obesity in the United States is <a href="https://www.cdc.gov/obesity/data/adult.html">$147 billion</a>, with most of those costs hitting public programs such as Medicare and Medicaid. Similar trends have been <a href="https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight">observed internationally among developed countries</a>.</p>
<p>So what can we do about it? The massive public and private efforts to control smoking provide both a template for addressing obesity and a benchmark for social impact. Tactics such as education, cigarette taxes, and smoke-free public spaces resulted in a 66% decline in smoking between 1965 and 2018, when cigarette smoking reached <a href="https://www.cdc.gov/media/releases/2019/p1114-smoking-low.html">an all-time low</a> of 13.7% among U.S. adults.</p>
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<a href="https://images.theconversation.com/files/311487/original/file-20200123-32170-1y2r7ra.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/311487/original/file-20200123-32170-1y2r7ra.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/311487/original/file-20200123-32170-1y2r7ra.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=396&fit=crop&dpr=1 600w, https://images.theconversation.com/files/311487/original/file-20200123-32170-1y2r7ra.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=396&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/311487/original/file-20200123-32170-1y2r7ra.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=396&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/311487/original/file-20200123-32170-1y2r7ra.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=498&fit=crop&dpr=1 754w, https://images.theconversation.com/files/311487/original/file-20200123-32170-1y2r7ra.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=498&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/311487/original/file-20200123-32170-1y2r7ra.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=498&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Cigarette smoking has plummeted in the U.S.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Cancer-Deaths-Decline/b99a642bd8a0426b985f6878b6083cb7/166/0">Jenny Kane/apimages.com</a></span>
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<p>This outcome is associated with major health <a href="https://www.ncbi.nlm.nih.gov/books/NBK53017/">improvements</a> – reduced cardiovascular disease, stroke, various cancers and mortality from lung cancer. Medicaid alone saves an estimated $2.5 billion a year from <a href="https://doi.org/10.1001/jamanetworkopen.2019.2307">smoking-related health improvements</a>.</p>
<p>From a public investment perspective, the potential bang for the buck is even <a href="https://doi.org/10.2307/41791016">bigger for obesity than it is for tobacco</a>. In my view, a successful anti-obesity campaign must encourage people to be less sedentary; invest in new medical treatments and nutrition science; and create regulatory and health insurance policies that reward behavioral change. It also means <a href="https://onlinelibrary.wiley.com/doi/full/10.1002/oby.22696">broader access to effective therapies</a>.</p>
<h2>Good ideas that aren’t working</h2>
<p>Our current emphasis on behavioral interventions has been disappointing. Society needs to find a way to talk about obesity and come up with ways to deal with it that do not involve <a href="https://labblog.uofmhealth.org/body-work/fat-shaming-wont-solve-obesity-science-might">body-shaming</a> Losing weight means eating less or exercising more, or both, but there are no guarantees with either approach. Getting people to exercise is difficult. <a href="https://health.gov/paguidelines/second-edition/pdf/Physical_Activity_Guidelines_2nd_edition.pdf">Nearly 80%</a> of adults are not meeting the key guidelines for both aerobic and muscle-strengthening activity. </p>
<p>Getting people to change their diet is similarly ineffective. <a href="http://newsroom.ucla.edu/releases/Dieting-Does-Not-Work-UCLA-Researchers-7832">According to one study</a>, half of dieters had gained 11 pounds five years after starting their diet; some progress but hardly enough. Similarly, nutritional labels <a href="https://www.ajpmonline.org/article/S0749-3797(18)32357-2/fulltext">have had little effect on consumers’ food intake and body mass index</a>.</p>
<p>So what should policymakers do? I think it is time to take several new approaches.</p>
<h2>Economic models for health intervention</h2>
<p>The intellectual property rights of companies that develop novel approaches to weight loss, such as mimicking the effects of exercise, should be protected and rewarded with patent law and other mechanisms. Currently, if a company discovers a way to get people to go for a walk with a new app or program, protection for intellectual property and reimbursement is uncertain. </p>
<p>Given the stakes, the U.S. government should offer greater rewards for behavioral interventions that can demonstrate long-term gains under the same rigorous regulatory standards similar to those required of new drugs. U.S. companies invest <a href="https://www.forbes.com/sites/johnlamattina/2018/06/12/pharma-rd-investments-moderating-but-still-high/#33152bc06bc2">billions of dollars to develop pharmaceuticals</a>. By contrast, there is <a href="https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2018.05187">less social investment</a> in other prevention activities. </p>
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<img alt="" src="https://images.theconversation.com/files/310535/original/file-20200116-181639-6cswc5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/310535/original/file-20200116-181639-6cswc5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/310535/original/file-20200116-181639-6cswc5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/310535/original/file-20200116-181639-6cswc5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/310535/original/file-20200116-181639-6cswc5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/310535/original/file-20200116-181639-6cswc5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/310535/original/file-20200116-181639-6cswc5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Excess weight carries great social cost.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Overweight-Kids-Diabetes/1771374a081541b5b5775ebf9418056f/5/0">Patrick Sison/APImages.com</a></span>
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<p>While not a solution for everyone, gastric bypass and adjustable gastric banding, among other procedures, have proven effective. New incentives could expand access to these surgeries by lowering the BMI threshold for eligibility. Some insurers have put up barriers to this treatment because obesity is not immediately life-threatening or related to our <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6179496/">traditional notion of disease</a>. </p>
<p>We need to find better ways to annuitize the cost of surgery and increase access while tying reimbursement to outcomes. Other insurers with an interest in long-term outcomes, <a href="https://www.wsj.com/articles/health-cares-killer-app-life-insurance-11553122054">including the life insurance industry</a>, can play an important role. They have a vested financial interest in avoiding mortality and disability but have traditionally remained on the sidelines while Americans grow fatter.</p>
<p>Evidence points to <a href="https://doi.org/10.1016/j.jhealeco.2012.04.006">a 20% reduction</a> in BMI persisting up to 10 years after surgery. In 2017, <a href="https://asmbs.org/articles/new-study-finds-most-bariatric-surgeries-performed-in-northeast-and-fewest-in-south-where-obesity-rates-are-highest-and-economies-are-weakest">228,000 Americans</a> received bariatric surgeries. Of those, only 10% of are eligible under current criteria. </p>
<p>Another approach is to consider <a href="https://www.niddk.nih.gov/health-information/weight-management/prescription-medications-treat-overweight-obesity">new medications</a> and utilize the successful approach that has been used to fight high blood pressure. About 50 years ago, hypertension was considered untreatable. Diet and exercise were the predominant means of controlling it. The discovery of multiple agents to combat hypertension, beginning with diuretics and beta blockers, proved transformative. A similar story emerged for elevated cholesterol. About half the decline in U.S. deaths from coronary heart disease can be attributed to <a href="https://doi.org/10.1056/NEJMsa053935">medical therapies</a> like these.</p>
<p>Several clinically proven anti-obesity medications are already available for people who do not respond to lifestyle modification. Furthermore, there is a robust clinical pipeline, with approximately <a href="https://www.pharmaceutical-technology.com/comment/obesity-pipeline/">250 compounds under development</a>, including dozens of novel compounds. Drugs such as these can help change the trajectory of the obesity epidemic, if they are made widely available and reimbursed — challenges in today’s health care insurance system.</p>
<p>Another avenue to consider includes <a href="https://www.taxpolicycenter.org/briefing-book/how-do-state-and-local-soda-taxes-work">levying taxes on sweetened beverages</a>, or the so-called “soda tax.” <a href="https://www.ncbi.nlm.nih.gov/pubmed/26094232">One study</a> found that implementing a 1 cent per ounce soda tax would reduce sugar-sweetened beverage consumption by 20% over 10 years. The result would be a $23.6 billion savings in health care and improved population health. </p>
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<a href="https://images.theconversation.com/files/310533/original/file-20200116-181634-1pg3a71.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/310533/original/file-20200116-181634-1pg3a71.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/310533/original/file-20200116-181634-1pg3a71.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/310533/original/file-20200116-181634-1pg3a71.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/310533/original/file-20200116-181634-1pg3a71.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/310533/original/file-20200116-181634-1pg3a71.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/310533/original/file-20200116-181634-1pg3a71.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/310533/original/file-20200116-181634-1pg3a71.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">In 2012, new laws required schools to limit salt and fat and cap calories.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Lunch-Debt-Donors/e71ef26a17da43eca4647608d0bac984/2/0">Mary Esch/APImages</a></span>
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<p>Finally, the food and restaurant industry deserves some of the blame. Restricting access – like the United States tried with the ban on the consumption and sale of alcohol – won’t work. But <a href="https://www.rand.org/blog/2014/01/the-conspiracy-to-keep-you-fat.html">responsible steps to regulate portions might</a>.</p>
<p>Smart, bold strategies helped us address public health crises before, including smoking and hypertension. We need to be similarly aggressive with obesity if we want to avert hundreds of thousands of unnecessary deaths. As we did with smoking, it is time to make obesity a number one public health priority.</p>
<p>[ <em><a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=expertise">Expertise in your inbox. Sign up for The Conversation’s newsletter and get a digest of academic takes on today’s news, every day.</a></em> ]</p><img src="https://counter.theconversation.com/content/129317/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr. Goldman is a consultant to Precision Health Economics and holds equity (<1%) in its parent company. He also reports grants from NIH, an honorarium from ACADIA Pharmaceuticals, and consulting for Novo Nordisk. </span></em></p>Nearly 40% of Americans are obese, and the numbers are climbing. The U.S. needs to get serious about solutions.Dana Goldman, Leonard D. Schaeffer Chair and Distinguished Professor of Public Policy, Pharmacy, and Economics, University of Southern CaliforniaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1182042019-06-10T12:18:17Z2019-06-10T12:18:17ZWeight-loss surgery in England: many who need it aren’t getting it<figure><img src="https://images.theconversation.com/files/278139/original/file-20190605-40719-1cd9jpf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1053684731?src=p6bMOpZWScNsmB8owq4uTQ-1-4&size=medium_jpg">ADragan/Shutterstock</a></span></figcaption></figure><p>Obese people who have weight-loss surgery (also known as bariatric surgery) <a href="https://www.ncbi.nlm.nih.gov/pubmed/24352617">live longer</a> than those who don’t and they have a <a href="https://www.ncbi.nlm.nih.gov/pubmed/26094664">better quality of life</a>. It is a <a href="https://www.ncbi.nlm.nih.gov/pubmed/29951614">relatively safe</a> procedure, and it is <a href="https://link.springer.com/article/10.1007/s11695-012-0679-z">cost-effective for the NHS</a>.</p>
<p>About <a href="https://link.springer.com/article/10.1007%2Fs11695-019-03977-3">3.6m people</a> in England are eligible for <a href="https://www.nhs.uk/conditions/weight-loss-surgery/">weight-loss surgery</a>, but the latest figures show that just <a href="https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-obesity-physical-activity-and-diet/statistics-on-obesity-physical-activity-and-diet-england-2019">6,627 people had this surgery in 2017-18</a>.</p>
<p>In 2014, the National Institute for Health and Care Excellence (NICE) updated its <a href="https://www.nice.org.uk/guidance/CG189">guidance on obesity</a> making weight-loss surgery available to people with type 2 diabetes. NICE now recommends that anyone who has been diagnosed with type 2 diabetes in the last ten years should be given an assessment of whether surgery is right for them if their body mass index (BMI) is over 30. This surgery is particularly beneficial for people with type 2 diabetes, allowing many who need drug treatment to stop taking medication within two years of surgery.</p>
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<img alt="" src="https://images.theconversation.com/files/278136/original/file-20190605-40723-p6p4o3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/278136/original/file-20190605-40723-p6p4o3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=420&fit=crop&dpr=1 600w, https://images.theconversation.com/files/278136/original/file-20190605-40723-p6p4o3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=420&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/278136/original/file-20190605-40723-p6p4o3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=420&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/278136/original/file-20190605-40723-p6p4o3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=528&fit=crop&dpr=1 754w, https://images.theconversation.com/files/278136/original/file-20190605-40723-p6p4o3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=528&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/278136/original/file-20190605-40723-p6p4o3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=528&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">BMI is calculated as your weight divided by your height squared.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/woman-body-mass-index-info-chart-1146462977?src=QqAPweCE_PUKcqAzyzKUvA-1-12">SVStudio/Shutterstock</a></span>
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<p>Considering how many people are obese in England, it appears that about <a href="https://link.springer.com/article/10.1007%2Fs11695-019-03977-3">0.2% of eligible people are getting surgery</a>. This is far lower than in other countries where similar methods of estimation suggest that <a href="https://doi.org/10.1016/j.soard.2016.08.488">1.2% of eligible people in the US</a> receive surgery and <a href="https://obesitycanada.ca/wp-content/uploads/2017/07/Report-Card-Full-Version-PDF.pdf">0.5% in Canada</a>. In 2016, the BMJ published an <a href="https://doi.org/10.1136/bmj.i1472">opinion piece</a> suggesting that we should aim for 50,000 weight-loss surgeries a year to be operating at a similar rate (operations per head of population) to the rest of Europe (about 1.4% of eligible people).</p>
<h2>Why are rates so low in England?</h2>
<p>Surprisingly, after the 2014 guidance update, which should have increased the availability of surgery for those with type 2 diabetes, the number of people receiving surgery each year in England fell from a high of <a href="https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-obesity-physical-activity-and-diet/statistics-on-obesity-physical-activity-and-diet-england-2019">8,794 in 2011-12 to 6,032 in 2014-15</a>, although the numbers have been creeping up again more recently.</p>
<p>One reason for the low number of operations performed in England is low demand from patients. A lot of <a href="https://doi.org/10.1186/s40608-015-0064-2">weight bias exists in the UK</a>. This might mean health professionals think that an obese person is to blame for their condition and doesn’t deserve surgery. The Royal College of Physicians recently called for obesity to be <a href="https://www.rcplondon.ac.uk/news/rcp-calls-obesity-be-recognised-disease">recognised as a disease</a>, which might help to promote treatment for those who could benefit from it.</p>
<p>Another worrying <a href="https://link.springer.com/article/10.1007%2Fs11695-019-03977-3">statistic</a> is that, while women are more likely than men to be eligible for surgery (58% vs 42%), the proportion of women receiving surgery is significantly higher (76% vs 24%). We know that <a href="https://www.ncbi.nlm.nih.gov/pubmed/23959757">men are less likely to go to the doctor with a health problem</a>, so they are probably also less likely to ask for help with their weight.</p>
<h2>Who is eligible?</h2>
<p>People who have tried to lose weight through exercise, diet or drugs but whose BMI remains higher than 40, are eligible for weight-loss surgery, as are people with a BMI over 35 who have a serious disease that might be worsened by their weight, such as high cholesterol, high blood pressure or osteoarthritis. And people with a BMI over 50 are eligible for surgery even if they haven’t tried to lose weight.</p>
<p>People with recent-onset type 2 diabetes and a BMI over 30 are also eligible for weight-loss surgery. (Type 2 diabetes diagnosed in the last ten years counts as “recent onset”.) </p>
<p>Weight-loss surgery is also recommended for people with a South-Asian ethnic background at lower BMIs than stated above. For example, people with recent onset diabetes with a BMI under 30.</p>
<p>Not everyone who is eligible for surgery should have it, though. Those who are eligible should be assessed to see if it’s right for them. People who have had weight-loss surgery describe lifelong physical, psychological and social consequences, both <a href="https://openarchive.ki.se/xmlui/handle/10616/46121">positive and negative</a>. The assessment should examine, for each individual, whether the potential benefits outweigh the risks. </p>
<p>Even though there is a group for whom weight loss surgery will not be right, the latest figures tell us that there is a very large group for whom it is right – and we know that that group isn’t having this life-changing procedure. There’s now a need to find out why.</p><img src="https://counter.theconversation.com/content/118204/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Oyinlola Oyebode receives funding from National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) West Midlands. She is a Fellow of the Faculty of Public Health.</span></em></p>Bariatric surgery can be life changing, so why are so few being offered the procedure in England?Oyinlola Oyebode, Associate Professor in Public Health, University of WarwickLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/884632017-12-26T14:37:01Z2017-12-26T14:37:01ZNew medical advances marking the end of a long reign for ‘diet wizards’<figure><img src="https://images.theconversation.com/files/199767/original/file-20171218-27607-p7u70a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The Wizard of Oz promised results he could not deliver but was convincing in his presentation. Diet wizards have done the same for decades. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/tom-margie/">Insomnia Cured Here/Flickr.com</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>For many years, the long-term success rates for those who attempt to lose excess body weight have hovered around <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4990387/">5-10 percent</a>. </p>
<p>In what other disease condition would we accept these numbers and continue on with the same approach? How does this situation sustain itself?</p>
<p>It goes on because the diet industry has generated <a href="http://www.sciencedirect.com/science/article/pii/S014067361461744X#cesec80">marketing fodder</a> that obscures scientific evidence, much as the Wizard of Oz hid the truth from Dorothy and her pals. There is a gap between what is true and what sells (remember the <a href="https://www.npr.org/sections/thesalt/2015/05/28/410313446/why-a-journalist-scammed-the-media-into-spreading-bad-chocolate-science">chocolate diet</a>?). And, what sells more often dominates the message for consumers, much as the wizard’s sound and light production succeeded in misleading the truth-seekers in the Emerald City.</p>
<p>As a result, the public is often directed to attractive, short-cut weight loss options created for the purposes of making money, while scientists and doctors document facts that are steamrolled into the shadows. </p>
<p>We are living in a special time, though – the era of <a href="https://www.nature.com/articles/nrgastro.2013.119">metabolic surgeries and bariatric procedures</a>. As a result of these weight loss procedures, doctors have a much better understanding of the biological underpinnings responsible for the failure to lose weight. These discoveries will upend the current paradigms around weight loss, as soon as we figure out how to pull back the curtain.</p>
<p>As a dual board-certified, interventional obesity medicine specialist, I have witnessed the experience of successful weight loss over and over again – clinically, as part of interventional trials and in my personal life. The road to sustained transformation is not the same in 2018 as it was in 2008, 1998 or 1970. The medical community has identified the barriers to successful weight loss, and we can now address them. </p>
<h2>The body fights back</h2>
<p>For many years, the diet and fitness industry has supplied folks with an unlimited number of different weight loss programs – seemingly a new solution every month. Most of these programs, on paper, should indeed lead to weight loss. At the same time, <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(02)08397-6/abstract">the incidence of obesity continues to rise at alarming rates</a>. Why? Because people cannot do the programs. </p>
<p>First, overweight and obese patients do not have the calorie-burning capacity to exercise their way to sustainable weight loss. What’s more, the same amount of exercise for an overweight patient is <a href="https://www.nature.com/articles/0803052">much harder</a> than for those who do not have excess body weight. An obese patient simply cannot exercise enough to lose weight by burning calories.</p>
<p>Second, the body will not let us restrict calories to such a degree that long-term weight loss is realized. The body fights back with <a href="http://mannlab.psych.umn.edu/">survival-based biological responses</a>. When a person limits calories, the body slows baseline metabolism to offset the calorie restriction, because it interprets this situation as a threat to survival. If there is less to eat, we’d better conserve our fat and energy stores so we don’t die. At the same time, also in the name of survival, the body sends out surges of hunger hormones that induce food-seeking behavior – creating a real, measurable resistance to this perceived threat of starvation. </p>
<p>Third, <a href="https://www.scientificamerican.com/article/how-gut-bacteria-help-make-us-fat-and-thin/">the microbiota in our guts are different</a>, such that “a calorie is a calorie” no longer holds true. Different gut microbiota pull different amounts of calories from the same food in different people. So, when our overweight or obese colleague claims that she is sure she could eat the same amount of food as her lean counterpart, and still gain weight – we should believe her. </p>
<h2>Lots of shame, little understanding</h2>
<p>Importantly, the lean population does not feel the same overwhelming urge to eat and quit exercising as obese patients do when exposed to the same weight loss programs, because they start at a different point. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/199763/original/file-20171218-27554-q71wyh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/199763/original/file-20171218-27554-q71wyh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=455&fit=crop&dpr=1 600w, https://images.theconversation.com/files/199763/original/file-20171218-27554-q71wyh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=455&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/199763/original/file-20171218-27554-q71wyh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=455&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/199763/original/file-20171218-27554-q71wyh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=572&fit=crop&dpr=1 754w, https://images.theconversation.com/files/199763/original/file-20171218-27554-q71wyh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=572&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/199763/original/file-20171218-27554-q71wyh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=572&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">French fries and chocolate milkshakes affect people differently. Some are tempted by them, and others are not.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/chocolate-ice-cream-glass-cup-whipped-346034765?src=2d7C-LrAcTRnSveGXLCSDA-2-48">Sheila Fitzgerald/Shutterstock.com</a></span>
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<p>Over time, this situation has led to stigmatizing and prejudicial fat-shaming, based on lack of knowledge. Those who fat-shame most often have never felt the biological backlash present in overweight and obese folks, and so conclude that those who are unable to follow their programs fail because of some inherent weakness or difference, a classic setup for discrimination.</p>
<p>The truth is, the people failing these weight loss attempts fail because they face a formidable entry barrier related to their disadvantaged starting point. The only way an overweight or obese person can be successful with regard to sustainable weight loss, is to directly address the biological entry barrier which has turned so many back.</p>
<h2>Removing the barrier</h2>
<p>There are three ways to minimize the barrier. The objective is to attenuate the body’s response to new calorie restriction and/or exercise, and thereby even up the starting points. </p>
<p>First, surgeries and interventional procedures work for many obese patients. They help by minimizing the biological barrier that would otherwise obstruct patients who try to lose weight. These procedures alter the hormone levels and metabolism changes that make up the entry barrier. They lead to weight loss by directly addressing and changing the biological response responsible for <a href="https://www.nature.com/articles/nrgastro.2013.119">historical failures</a>. This is critical because it allows us to dispense with the antiquated “mind over matter” approach. These are not “willpower implantation” surgeries, they are metabolic surgeries. </p>
<p>Second, medications play a role. The FDA has approved <a href="https://www.medscape.com/viewarticle/876411">five new drugs</a> that target the body’s hormonal resistance. These medications work by directly attenuating the body’s survival response. Also, stopping medications often works to minimize the weight loss barrier. Common medications like antihistamines and antidepressants are often <a href="https://academic.oup.com/jcem/article/100/2/342/2813109">significant contributors to weight gain</a>. Obesity medicine physicians can best advise you on which medications or combinations are contributing to weight gain, or inability to lose weight. </p>
<p>Third, increasing <a href="https://www.ncbi.nlm.nih.gov/books/NBK404/">exercise capacity</a>, or the maximum amount of exercise a person can sustain, works. Specifically, it changes the body so that the survival response is lessened. A person can increase capacity by attending to recovery, the time in between exercise bouts. Recovery interventions, such as food supplements and sleep, lead to increasing capacity and decreasing resistance from the body by reorganizing the biological signaling mechanisms – a process known as retrograde neuroplasticity.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/199760/original/file-20171218-27538-8uh939.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/199760/original/file-20171218-27538-8uh939.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=466&fit=crop&dpr=1 600w, https://images.theconversation.com/files/199760/original/file-20171218-27538-8uh939.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=466&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/199760/original/file-20171218-27538-8uh939.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=466&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/199760/original/file-20171218-27538-8uh939.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=585&fit=crop&dpr=1 754w, https://images.theconversation.com/files/199760/original/file-20171218-27538-8uh939.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=585&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/199760/original/file-20171218-27538-8uh939.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=585&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Strength conditioning builds muscle mass, which can help increase capacity.</span>
<span class="attribution"><a class="source" href="http://www.uconnruddcenter.org/_tools/imageViewer.cfm?id=180&c=2&r=0">Rudd Center for Food Policy and Obesity</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>Lee Kaplan, director of the Harvard Medical School’s Massachusetts Weight Center, captured this last point during a recent lecture by saying, “We need to stop thinking about the Twinkie diet and start thinking about physiology. Exercise alters food preferences toward healthy foods … and healthy muscle trains the fat to burn more calories.” </p>
<p>The bottom line is, obese and overweight patients are exceedingly unlikely to be successful with weight loss attempts that utilize mainstream diet and exercise products. These products are generated with the intent to sell, and the marketing efforts behind them are comparable to the well-known distractions generated by the Wizard of Oz. The reality is, the body fights against calorie restriction and new exercise. This resistance from the body can be lessened using medical procedures, by new medications or by increasing one’s exercise capacity to a critical point. </p>
<p>Remember, do not start or stop medications on your own. Consult with your doctor first.</p><img src="https://counter.theconversation.com/content/88463/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Prologo is the founder and CEO of The Catching Point, LLC (<a href="http://www.catchingpoint.com">www.catchingpoint.com</a>). </span></em></p>Dieting fads have been around for more than a century, but none of them has been shown to curb obesity long-term. The good news is that scientific evidence is revealing treatments that do work.J. David Prologo, Associate Professor, Department of Radiology and Imaging Sciences, Emory UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/627602016-08-04T01:28:38Z2016-08-04T01:28:38ZDon’t let the scale fool you: Why you could still be at risk for diabetes<figure><img src="https://images.theconversation.com/files/132842/original/image-20160802-17177-dbpl2r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Working out can help you avoid diabetes, but being thin is no guarantee. </span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-70613011/stock-photo-senior-woman-in-a-gym-exercising-with-barbell.html?src=pd-photo-55470985-M_n9I6ZauCXJ_Vqfe0L46A-7">From www.shuttterstock.com</a></span></figcaption></figure><p>Type 2 diabetes has reached <a href="http://www.cdc.gov/features/diabetesfactsheet/">epidemic proportions</a>, with an estimated 29 million people in the U.S. having the disease and another 86 million considered prediabetic. With an estimated cost of US$245 billion, prevention becomes critically important to stem the tide of increasing diabetes prevalence.</p>
<p>Diabetes is a chronic, treatable disease, but there are no cures. <a href="http://www.ahchealthenews.com/2016/06/01/study-people-diabetes-can-benefit-weight-loss-surgery/">Weight loss surgery</a> has been shown to help in some individuals, and medication can help. Identifying individuals at high risk for development of diabetes, adults with prediabetes, and then providing treatment to them is an effective strategy <a href="http://www.cdc.gov/diabetes/basics/prevention.html">to slow or eliminate</a> its progression. </p>
<p>The prevailing wisdom and screening and treatment recommendations begin with the starting point that adults who are overweight or obese are the ones who are likely to have prediabetes. <a href="http://www.mayoclinic.org/diseases-conditions/prediabetes/basics/treatment/con-20024420">Weight loss</a> for those individuals is the primary recommended lifestyle intervention. Exercise and eating healthy foods are part of that. </p>
<p>As someone who has studied diabetes, I have discovered recently with colleagues that we <a href="http://www.annfammed.org/content/14/4/304.long">may be missing</a> millions of adults with prediabetes. Our screening systems in the U.S. are focusing only on these individuals who are <a href="http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/screening-for-abnormal-blood-glucose-and-type-2-diabetes">overweight or obese</a>. </p>
<p>Our studies suggest it may not be as simple as classifying people as overweight or obese versus healthy. Our thinking of risk and screening should also consider body composition. </p>
<h2>A hidden danger</h2>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/132843/original/image-20160802-17183-1te54o2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/132843/original/image-20160802-17183-1te54o2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/132843/original/image-20160802-17183-1te54o2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/132843/original/image-20160802-17183-1te54o2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/132843/original/image-20160802-17183-1te54o2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/132843/original/image-20160802-17183-1te54o2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/132843/original/image-20160802-17183-1te54o2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Muscle loss from aging and a sedentary lifestyle is common.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/dl2_lim.mhtml?src=TOuFw4U_Z7HbTHT11rPIFw-1-4&clicksrc=download_btn_inline&id=141131089&size=huge_jpg&submit_jpg=">From www.shutterstock.com</a></span>
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</figure>
<p>In an analysis of nationally representative data looking at 18 year trends in prediabetes among healthy weight adults, in 2012, 33 percent of adults 45 and older at “healthy weight” in the United States had <a href="http://care.diabetesjournals.org/content/39/Supplement_1/S13">prediabetes</a>, defined as a Hemoglobin A1c of 5.7 percent to 6.4 percent. The proportion of adults at healthy weight with prediabetes had shown a significant rise over time. This is particularly troubling because the health care authorities have told this group that they are “healthy,” and we are not looking for diabetes in them. </p>
<p>The screening recommendations of the United States Preventive Services Task Force suggests screening for abnormal blood glucose (prediabetes and diabetes) only in adults who are <a href="http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/screening-for-abnormal-blood-glucose-and-type-2-diabetes">overweight or obese</a>. Based upon these guidelines, millions may be leaving their doctor’s offices with an unidentified risk for one of the most debilitating and expensive chronic illnesses in the U.S. </p>
<p>Moreover, since these adults are what we would consider to be a healthy weight, the usual strategy of calorie restriction and weight loss is called into question as an appropriate prevention strategy. </p>
<p>These findings make us wonder whether we need to shift our thinking about what may predispose one to prediabetes and how to prevent and delay progression to diabetes in this high-risk population. </p>
<p>Instead of looking only at weight, we should think in terms of a healthy body composition represented by the proportion of lean body mass to fat. People at healthy weight but poor body composition that is, someone with low weight but also low muscle mass in proportion to their body fat, what some have termed “<a href="http://www.mensfitness.com/training/pro-tips/skinny-fat-epidemic">skinny fat.”</a> </p>
<p>We think a healthy body composition is more important than weight. Body composition refers to the proportion of lean body mass to fat. Over time, that proportion changes, as some muscle loss is inevitable from aging.</p>
<p>We may not be able to see this change in in our bodies or on the scale. A 55-year-old man, for example, who still weighs close to what he weighed at 25 will have a different proportion of lean body mass to fat, with more fat most likely. </p>
<p>Although some lean muscle mass loss is inevitable as we age, exercise can counteract some of the loss. Unfortunately for us, as our industrialized society moves to a sedentary lifestyle, getting that exercise becomes more of a challenge.</p>
<p>Just as society has shifted in our activity levels, we may have to shift our thinking about health. We may be working with a false dichotomy that of overweight and obese versus healthy. </p>
<h2>Getting a grip can help</h2>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/132844/original/image-20160802-17183-10onrlt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/132844/original/image-20160802-17183-10onrlt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/132844/original/image-20160802-17183-10onrlt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/132844/original/image-20160802-17183-10onrlt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/132844/original/image-20160802-17183-10onrlt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/132844/original/image-20160802-17183-10onrlt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/132844/original/image-20160802-17183-10onrlt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Hand dynamometer.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/downloading_tips.mhtml?code=&id=8978941&size=medium&image_format=jpg&method=download&super_url=http%3A%2F%2Fdownload.shutterstock.com%2Fgatekeeper%2FW3siZSI6MTQ3MDE4NTg0NSwiYyI6Il9waG90b19zZXNzaW9uX2lkIiwiZGMiOiJpZGxfODk3ODk0MSIsImsiOiJwaG90by84OTc4OTQxL21lZGl1bS5qcGciLCJtIjoiMSIsImQiOiJzaHV0dGVyc3RvY2stbWVkaWEifSwiWTlleEo3M2lXTGUyV1NXeWJFQTRvcTlLck1JIl0%2Fshutterstock_8978941.jpg&racksite_id=ny&chosen_subscription=1&license=standard&src=QxvtMLaM7PIv2ulPJOlQdg-1-2">From www.shutterstock.com</a></span>
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<p>We have conducted <a href="http://www.jabfm.org/content/29/2/280.long">several</a> <a href="http://www.sciencedirect.com/science/article/pii/S0749379715002676">studies</a> that suggest there may be a simple way to screen for lean muscle mass. We can test grip strength, as measured by a <a href="http://www.topendsports.com/testing/tests/handgrip.htm">hand grip dynamometer</a>, an instrument that measures the strength of hand and forearm muscles. This could be done in a doctor’s office in a very non-intrusive way in about 30 seconds.</p>
<p>We found that among individuals at healthy weight, lower grip strength is associated not only with undiagnosed diabetes in adults but also prediabetes. Thus, by focusing on muscle and body composition, we can distinguish individuals in the healthy weight category who have abnormal blood glucose, an indicator of prediabetes or diabetes. </p>
<p>We haven’t established the cut-points, or measurements, of grip strength for use in practice with different patient populations (e.g., young men, old women, tall men), but that is where we need to go in future studies.</p>
<p>This helps us to rethink not only how we view the illness but also who may be at risk. Further, it also helps us think of potential strategies to deal with this problem. </p>
<p>For example, what are the next steps for individuals who are at a healthy weight? They are already at a suggested healthy weight, but that is providing a misleading assurance of health for many of these adults. To avoid missing these people, should we consider expanding the current Preventive Services Task Force recommendations of screening for abnormal blood glucose to include adults at healthy weight as well as those who are overweight or obese? </p>
<p>It is unclear whether that type of expansion would be cost effective. Would it be better to focus on refining our measures of body composition among individuals at healthy weight to select those at the highest risk?</p>
<p>It is still premature to recommend specific interventions for individuals at healthy weight to prevent diabetes. It may, however, be worthwhile to emphasize resistance exercise in a healthy lifestyle rather than having individuals focus on what the scales say about their weight. Think body composition, not just thin.</p><img src="https://counter.theconversation.com/content/62760/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Arch Mainous does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Diabetes afflicts nearly 30 million people in the U.S., but 86 million more are pre-diabetic. There are effective ways to screen those people, too – and it isn’t all about fat.Arch Mainous, Professor of Public Health , University of FloridaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/226962014-02-14T03:30:41Z2014-02-14T03:30:41ZExplainer: the risks and benefits of bariatric surgery<figure><img src="https://images.theconversation.com/files/41404/original/k8x7wb5q-1392243793.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Bariatric surgery is the last-line option for weight loss.</span> <span class="attribution"><span class="source">Chris J/FLickr</span></span></figcaption></figure><p>You don’t need an expert to tell you obesity has become a major health problem worldwide. The <a href="http://www.who.int/mediacentre/factsheets/fs311/en/">World Health Organisation estimates</a> 35% of the world’s adults are overweight and 11% obese, double the rate in 1980. </p>
<p>Overweight and obese people have an increased risk of high blood pressure, type 2 diabetes and cardiovascular disease, as well as arthritis, obstructive sleep apnoea and liver disease. Obesity can <a href="http://www.ncbi.nlm.nih.gov/pubmed/12517229">reduce life expectancy</a> by five to 20 years, and the obesity epidemic may soon reverse the gains that have been made in human longevity.</p>
<p>We could simply eat less and move more. But, of course, it’s not that simple; many of us find it impossible to consistently control our calorie intake. For those with severe obesity or diabetes who have tried all other medical options but failed to lose weight, bariatric surgery is the last-line option. </p>
<p>Bariatric surgery refers to a group of surgical procedures that make it more difficult to over eat and/or absorb food. It is recognised as the <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa066254">most effective treatment</a> for obesity, resulting in both the largest and most sustained weight loss, and the greatest reduction in obesity-related disease and death.</p>
<p>But it is highly invasive, it comes with a number of risks and in some cases is not effective.</p>
<h2>Types of surgery</h2>
<p>There are three main types of bariatric surgery available in Australia: laparoscopic adjustable gastric band (LAGB), sleeve gastrectomy and gastric bypass. All of these procedures can now be performed with keyhole surgery.</p>
<p><strong>Laparoscopic adjustable gastric band</strong></p>
<p>LAGB is a relatively simple operation in which an adjustable silicone balloon ring is placed around the upper stomach. As well as restricting the volume of food the stomach can hold, the pressure created by food in the reduced upper stomach stimulates the vagal nerve, reducing appetite.</p>
<p>But it is easier to consume fluids than denser, healthier foods, reducing the quality of the diet, which might explain why LAGB <a href="http://www.ncbi.nlm.nih.gov/pubmed/24352617">results in less weight loss</a> than other procedures. </p>
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<a href="https://images.theconversation.com/files/41517/original/vhd2y4ks-1392339701.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/41517/original/vhd2y4ks-1392339701.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/41517/original/vhd2y4ks-1392339701.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=572&fit=crop&dpr=1 600w, https://images.theconversation.com/files/41517/original/vhd2y4ks-1392339701.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=572&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/41517/original/vhd2y4ks-1392339701.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=572&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/41517/original/vhd2y4ks-1392339701.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=719&fit=crop&dpr=1 754w, https://images.theconversation.com/files/41517/original/vhd2y4ks-1392339701.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=719&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/41517/original/vhd2y4ks-1392339701.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=719&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<p>For sustained weight loss, close follow up is needed, with optimal adjustment of the band; if the band is too tight, it’s difficult to eat healthy foods and obstruction may occur, if the band is too loose, appetite is not controlled. </p>
<p>Revision surgery is required in about 15% of patients within three years due to band slippage and erosion of the band into the stomach wall.</p>
<p>Side effects include <a href="https://theconversation.com/explainer-what-is-gastric-reflux-18791">gastric reflux</a>. </p>
<p><strong>Sleeve gastrectomy</strong></p>
<p>In this procedure, most of the stomach is removed. It is technically simple and is <a href="http://www.deepdyve.com/lp/springer-journals/laparoscopic-sleeve-gastrectomy-as-a-single-stage-procedure-for-the-JYwV3tyZ0n">reported to have</a> a good safety profile in experienced hands. </p>
<p>The weight loss and improvement in diabetes is related to both reduced capacity of the stomach and an increase in hormones that reduce appetite and increase meal related insulin release.</p>
<p>Nutritional deficiencies are common and most people need supplements of nutrients normally absorbed by the stomach. Surgical complications include leakage or bleeding at the suture line. </p>
<p>This procedure is the newest and there is less long-term data than for other procedures.</p>
<p><strong>Gastric bypass</strong></p>
<p>This operation creates a small proximal stomach joined to the end of the jejunum (the lower small bowel) so that parts of the small bowel, where nutrients are absorbed, are bypassed. While a more extensive operation, it can be reversed because nothing is removed. </p>
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<a href="https://images.theconversation.com/files/41521/original/rqztp8j6-1392339950.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/41521/original/rqztp8j6-1392339950.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/41521/original/rqztp8j6-1392339950.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=440&fit=crop&dpr=1 600w, https://images.theconversation.com/files/41521/original/rqztp8j6-1392339950.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=440&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/41521/original/rqztp8j6-1392339950.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=440&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/41521/original/rqztp8j6-1392339950.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=553&fit=crop&dpr=1 754w, https://images.theconversation.com/files/41521/original/rqztp8j6-1392339950.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=553&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/41521/original/rqztp8j6-1392339950.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=553&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<p>Gastric bypass results in <a href="http://archsurg.jamanetwork.com/article.aspx?articleid=1790378">more weight loss</a> than the sleeve gastrectomy as there is both a reduction in the capacity of the stomach and reduced absorption of nutrients, including the beneficial changes in gut hormones seen with the sleeve gastrectomy.</p>
<p>In some patients, the weight loss is so great that they become malnourished and all patients require life-long supplements of vitamins, calcium and other minerals. There is also the risk of “dumping syndrome” due to the rapid transit of undigested food from the new, smaller stomach to the bowel, causing nausea, cramps, diarrhoea, and occasionally low blood sugar from very high insulin levels. </p>
<p>Surgical complications include leakage, bleeding and bowel obstruction.</p>
<h2>Risks and long-term effects</h2>
<p>In addition to the complications of surgery and malnutition, the long-term effects can include <a href="http://www.thelancet.com/journals/landia/article/PIIS2213-8587(13)70183-9/abstract">reduced bone density</a> and <a href="http://archneur.jamanetwork.com/article.aspx?articleid=786290">impairment in nerve function</a>. </p>
<p>There is also a reported increased incidence of suicide and <a href="http://archsurg.jamanetwork.com/article.aspx?articleid=1379763">substance abuse</a> in patients who have had bariatric surgery. But there have been few controlled studies comparing the quality of life after surgery with patients who have not sought surgery. </p>
<p>It’s important to note that individuals do not need to attain the amount of weight loss achieved with surgery to have substantial beneficial health outcomes. A reduction in weight of 5% to 10% <a href="http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf">can improve</a> the health of your heart and reduce obesity-related disease and early death, especially if combined with increased physical activity.</p>
<h2>Eligibility</h2>
<p>The current guidelines in most countries, <a href="http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/n57_obesity_guidelines_130531.pdf">including Australia</a>, are that bariatric surgery is indicated in people with a <a href="https://theconversation.com/explainer-overweight-obese-bmi-what-does-it-all-mean-7011">body mass index</a> (BMI, kg/m2) of greater than 40 or a BMI over 35 with serious health problems, such as type 2 diabetes. </p>
<p>These guidelines are based on those developed by the United States’ National Institute of Health (NIH) in 1991, when a different range of operations were available and surgery was not performed laparoscopically. Because of this, <a href="http://www.bariatricnews.net/?q=news/11795/asmbs-support-bariatric-surgery-bmi">some researchers</a> have recommended governments lower the threshold of eligibility to include people with a BMI over 30 without metabolic complications.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/41515/original/xf6sq7tp-1392339509.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/41515/original/xf6sq7tp-1392339509.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/41515/original/xf6sq7tp-1392339509.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/41515/original/xf6sq7tp-1392339509.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/41515/original/xf6sq7tp-1392339509.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/41515/original/xf6sq7tp-1392339509.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/41515/original/xf6sq7tp-1392339509.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Losing just 5% to 10% of your body weight can improve your health, especially if it’s coupled with exercise.</span>
<span class="attribution"><span class="source">Image from shutterstock.com</span></span>
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<p>The reduction of the threshold may result in too many people having surgery inappropriately. While bariatric surgery is the most robust treatment for obesity, it is invasive, often irreversible and has associated risks. </p>
<p>Despite the proven efficacy of bariatric surgery, there is no way that it can be delivered on a mass scale. This surgery should be reserved for patients with severe obesity or patients with diabetes who have been compliant with treatment but have been resistant to medical treatments. </p>
<p>Furthermore, there are many new treatments in the pipeline that may mimic the beneficial effects of surgery, such as medications with effects on multiple hormone pathways and less invasive surgical procedures that may be as effective as the current operations with fewer complications.</p><img src="https://counter.theconversation.com/content/22696/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tania Markovic received money from the Australian Egg Corp to do a study looking at the impact of eggs on people with type 2 diabetes. She is on the Egg nutrition council and Optifast advisory board.</span></em></p>You don’t need an expert to tell you obesity has become a major health problem worldwide. The World Health Organisation estimates 35% of the world’s adults are overweight and 11% obese, double the rate…Tania Markovic, Director, Metabolism & Obesity Services, Royal Prince Alfred Hospital; Clinical Associate Professor, The Boden Institute of Obesity, Nutrition, Exercise & Eating Disorders, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/67562012-06-07T04:15:53Z2012-06-07T04:15:53ZBariatric surgery works, we just need to ensure it’s safe<figure><img src="https://images.theconversation.com/files/10820/original/wmvwtfth-1337321954.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Establishing a bariatric register will provide confidence that bariatric surgery is safe.</span> <span class="attribution"><span class="source">flickr/Jacquiscloset</span></span></figcaption></figure><p>Around <a href="http://www.abs.gov.au/ausstats/abs@.nsf/Products/73E036F555CE4C11CA25789C0023DAF8?opendocument">2.6 million or 10% of Australians</a> are obese. Obesity contributes to other diseases, such as diabetes, high blood pressure, obstructive sleep apnoea, infertility, depression and cancer. The strength of this causal link means obesity is now considered at least equal to smoking as a preventable cause of premature death. </p>
<p>The total annual cost of obesity in Australia, including health system costs, productivity declines and carers’ costs, is <a href="http://www.diabetesaustralia.com.au/PageFiles/7830/FULLREPORTGrowingCostOfObesity2008.pdf">estimated at around A$58bn</a>. It’s morbidity and cost (as well as prevalence) has led Australian governments to recognise obesity as a <a href="http://www.aihw.gov.au/obesity-health-priority-area/#why_asthma">chief health priority</a>, at both the federal and state levels. </p>
<p>Weight loss has the potential to be an important health-care intervention in our community. The problem is that diet and exercise programs are typically only successful in the short term. Only 3% of people who successfully lose weight can maintain that loss beyond three years. This is not because these individuals are in some way inept or unwilling, but because our bodies are designed to defend fat mass. </p>
<p>Hunger is a primitive instinct. In evolutionary terms, fat stores represented stored energy that’s vital in case of famine. When someone loses weight, the body strives to replace depleted energy stores. Their metabolic rate slows down so that people seeking <a href="http://www.ncbi.nlm.nih.gov/pubmed/11375440">substantial weight loss and maintenance</a> need only 1200 kCal (1,000 calories) a day – the equivalent of three entrée-sized meals. If more than this very small amount of food is consumed, weight will be regained.</p>
<p>Losing weight also shifts our hormonal balance so that we become hungrier, making it almost impossible to adhere to the stringent long-term need for caloric restriction. In a society where there is an oversupply of tasty, attractive, hygienic food that is cheap, well marketed and very much a part of our cultural life, it’s difficult to not eventually satiate this new-found hunger.</p>
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<img alt="" src="https://images.theconversation.com/files/10111/original/g27nf86r-1335764927.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/10111/original/g27nf86r-1335764927.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/10111/original/g27nf86r-1335764927.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/10111/original/g27nf86r-1335764927.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/10111/original/g27nf86r-1335764927.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/10111/original/g27nf86r-1335764927.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/10111/original/g27nf86r-1335764927.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Dieting can make us hungrier, making it difficult to maintain a restricted-calorie diet.</span>
<span class="attribution"><span class="source">CeresB/Flickr</span></span>
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<p>Drugs have been tried to help tackle either the hunger associated with weight loss or the metabolic slow down. Unfortunately, their <a href="http://www.fda.gov/safety/medwatch/safetyinformation/safetyalertsforhumanmedicalproducts/ucm228830.htm">side effects have led to most being withdrawn</a> from the Australian market. </p>
<p>Obesity (bariatric) surgery becomes an option when someone has tried, and failed, to lose weight. Results from specialist centres and clinical trials suggest this procedure provides significant weight loss safely and that the loss persists beyond ten years. Weight loss is accompanied with significant <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa066254">improvement in the illnesses</a> associated with obesity and in quality of life. </p>
<p>Obese people who undergo bariatric surgery appear to live longer than obese people who don’t. On the basis of these results, there’s been a rapid expansion in the number of bariatric procedures performed in Australia annually; an estimated 13,000 procedures will be undertaken across Australia in 2012, up from 5,000 in 2005. </p>
<p>But while results from specialist centres suggest the surgery is safe, there’s no such thing as a risk-free surgical procedure. All surgery carries risks, such as bleeding, blood clots, infection, device or staple line failure. We currently have little information on the quality and safety of the surgery being performed in the general community, outside of specialist centres, and no way of tracking long-term safety and results. </p>
<p>To address this, a bariatric registry has been established by the <a href="http://www.ossanz.com.au/">Obesity Surgery Society of Australia and New Zealand</a> in conjunction with the NHMRC <a href="http://www.crepatientsafety.org.au/">Centre for Research Excellence in Patient Safety</a>. Currently in its pilot phase, the registry aims to capture and track all bariatric procedures performed across Australia and New Zealand, focusing not only on the safety of the initial procedure but also longer-term effects on weight and health, as well as any adverse events. </p>
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<img alt="" src="https://images.theconversation.com/files/10637/original/9km3dj2h-1336974358.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/10637/original/9km3dj2h-1336974358.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=901&fit=crop&dpr=1 600w, https://images.theconversation.com/files/10637/original/9km3dj2h-1336974358.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=901&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/10637/original/9km3dj2h-1336974358.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=901&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/10637/original/9km3dj2h-1336974358.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1133&fit=crop&dpr=1 754w, https://images.theconversation.com/files/10637/original/9km3dj2h-1336974358.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1133&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/10637/original/9km3dj2h-1336974358.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1133&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p>Quality and safety registries have been shown to improve health outcomes. Monitoring of outcomes following orthopaedic surgery through the <a href="http://www.dmac.adelaide.edu.au/aoanjrr/">Australian Joint Replacement Registry</a>, for instance, recently led to the withdrawal of a defective hip prosthesis from the market. </p>
<p>The establishment of this registry is in line with the 2008 recommendations of the <a href="http://www.safetyandquality.gov.au/">Australian Commission on Safety and Quality in Healthcare</a> and the <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/hta-review-report">2009 Health Technology Review report</a>. </p>
<p>There are also two specific recommendations for the establishment of a bariatric surgical registry: the Georganas Senate inquiry into obesity (2009) and the 2011 <a href="http://www.health.gov.au/MBRTG">Medical Benefits Reviews Task Group</a>.</p>
<p>While prevention is the ideal, we are now faced with a situation where <a href="http://www.abs.gov.au/ausstats/abs@.nsf/Products/73E036F555CE4C11CA25789C0023DAF8?opendocument">almost a quarter of our population</a> needs help to lose weight and keep it off. </p>
<p>Bariatric surgery appears to be a safe, reliable option for people who’ve failed to lose weight. The establishment of a bi-national bariatric register will provide confidence to patients, surgeons, funders, hospitals and the wider community that bariatric surgery is safe and improving the health of patients. </p><img src="https://counter.theconversation.com/content/6756/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Wendy Brown's research group at Monash University receives funding from Allergan Health and Applied Medical as well as the National Health and Medical Research Council. She received an honorarium to attend a Surgical Advisory Committee for Allergan Health in 2009. </span></em></p>Around 2.6 million or 10% of Australians are obese. Obesity contributes to other diseases, such as diabetes, high blood pressure, obstructive sleep apnoea, infertility, depression and cancer. The strength…Wendy Brown, Director, Centre for Obesity Research and Education & Associate Professor, Department of Surgery, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/23932011-08-11T04:30:45Z2011-08-11T04:30:45ZBariatric surgery: new paradigm in type 2 diabetes management?<figure><img src="https://images.theconversation.com/files/2835/original/5182304279_b3f30505d9_o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Bariatric surgery has a dramatic effect on diabetes and other heart disease risk factors.</span> <span class="attribution"><span class="source">Bariatric Solutions/www.mybariatricsolutions.com</span></span></figcaption></figure><p>Type 2 diabetes is the fastest growing epidemic worldwide. By 2020, it is expected to be the number one disease in Australia in men and second only to breast cancer in women. </p>
<p>Treating this illness has always been the ambit of physicians but big changes are afoot. </p>
<p>Diabetes specialists have recently seen a paradigm shift as surgeons invade our territory, laying claim to significant success in treating obese people with type 2 diabetes with bariatric surgery.</p>
<h2>The rise of bariatric surgery</h2>
<p>Bariatric surgery refers to operations on the stomach and/or intestines that help people with extreme obesity lose weight. </p>
<p>And the outcomes are very promising indeed: surgery can improve metabolic control of diabetes, as well as remission in many instances.</p>
<p>Lifestyle interventions including weight loss and exercise remain the first line treatment for type 2 diabetes but are <a href="http://theconversation.com/weighing-up-the-options-on-obesity-847">successful for very few</a>. </p>
<p>Usually, treatment with blood sugar lowering tablets is required and even then diabetes progresses.</p>
<p>It’s often necessary to use a combination of two or more tablets and insulin injections to control blood sugar levels. </p>
<p>While oral drugs and insulin play an important role, they can also cause significant weight gain: this is counter-intuitive for treatment of type 2 diabetes. </p>
<p>So we end up a “catch 22” situation as doctor and patient struggle to treat diabetes by using drugs that can increase weight.</p>
<p>This scenario raises questions about the best strategy for treating diabetes. </p>
<p>So it’s little wonder that bariatric surgery has appeal – it has a dramatic effect on diabetes as well as other heart disease risk factors and it’s cost effective. </p>
<h2>Guidance from an international body</h2>
<p>The increasing number of bariatric operations for people with type 2 diabetes globally led the International Diabetes Federation (IDF) to issue guidance to health professionals involved in caring for diabetics. </p>
<p>A multidisciplinary group of diabetologists and surgeons met in Belgium in December 2010 to develop a <a href="http://www.idf.org/media-events/press%20releases/2011/idf-announces-new-position%20supporting-surgery-treat-type-2-diabetes">position statement</a>.</p>
<p>The major objective of the statement was to place the role of bariatric surgery in a public health, clinical and socio-economic perspective. </p>
<p>The IDF statement recognises bariatric surgery as an appropriate treatment for obese people with type 2 diabetes who don’t achieve recommended targets with available medical therapies, especially when they face other major heart disease risk factors, such as high blood pressure and high cholesterol. </p>
<p>Surgery should now be accepted as a standard option in people with diabetes with a BMI of 35 or more. </p>
<p>Body mass index (BMI) is a standard way of measuring obesity. It is derived with the formula BMI = weight/height<sup>2</sup>. The <a href="http://www.who.int/mediacentre/factsheets/fs311/en/index.html">World Health Organisation recommendation</a> is that a BMI of less than 25 is normal, 25 to less than 30 is overweight and greater than 30 is obese. </p>
<p>Surgery should also be considered for patients with BMI between 30 and 35 when diabetes is inadequately controlled despite optimal medical therapy, especially in the presence of other major risk factors.</p>
<p>The IDF report stresses the importance of having a long-term multidisciplinary care team as well as use of safe and standardized surgical procedures. </p>
<p>It now recommends surgery be provided as an option in treatment protocols for obese patients with type 2 diabetes. </p>
<h2>Harmonising voices</h2>
<p>This builds on the view of an expert group of Australian and New Zealand diabetologists who <a href="http://www.obesityresearchclinicalpractice.com/article/S1871-403X(10)00290-5/fulltext">published their consensus</a> on bariatric surgery in the journal Obesity Research and Clinical Practice. </p>
<p>Bariatric surgery is expensive and, while freely available in the private health system, there is currently very limited access to it in the public arena. </p>
<p>But economic studies have shown it to be cost-effective compared with the lifelong costs of treating type 2 diabetes.</p>
<p>Equity of access to this surgery is a very important issue and there is increasing pressure for greater availability in the public system as <a href="http://www.mja.com.au/public/issues/195_03_010811/pro11117_fm.html">argued recently in a widely reported article</a> published in the <a href="http://www.mja.com.au">Medical Journal of Australia</a>.</p>
<p>Such surgery should now be considered earlier in the treatment of type 2 diabetes and no longer held out as a last resort. </p>
<p>The $64-million dollar question is whether there will be a dramatic change in the way type 2 diabetes is managed as a result of introducing what is initially a riskier surgical option. </p>
<p>It’s introduction into treatment protocols could transform diabetes care at large, particularly as up to 60% of people with type 2 diabetes could theoretically qualify. </p>
<p>The IDF position statement is intended to create awareness of the availability of surgery in treating type 2 diabetes when existing medical therapies fail. </p>
<p>Most governments, federal and state, have hugely underestimated the financial costs of obesity and type 2 diabetes. </p>
<p>While bariatric surgery will never be the answer to the public health crisis caused by the obesity and diabetes epidemics, it’s cost effective over the life of an obese person with type 2 diabetes. </p>
<p>Not only that, it can significantly improve the length and quality of life for people with type 2 diabetes.</p><img src="https://counter.theconversation.com/content/2393/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Zimmet has received payment for consultant advice to Covidien.</span></em></p>Type 2 diabetes is the fastest growing epidemic worldwide. By 2020, it is expected to be the number one disease in Australia in men and second only to breast cancer in women. Treating this illness has…Paul Zimmet, Professor (Hon) at Monash University, Baker Heart and Diabetes InstituteLicensed as Creative Commons – attribution, no derivatives.