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Bariatric surgery associated with longer survival

10 February 2015

Hi Everyone.  This study is answering the 'holy grail' of Bariatric surgery outcomes - does it prevent early, obesity related death?  And now we can say the answer is yes.  The exciting thing is just how big the beneficial effect is - 53% lower risk of dying.  That is really significant.  I would also applaud the other questions mentioned at the end of the article which constitutes ongoing research.  The thing that the public hospital system wants answered is whether these improvements given to patients through weight loss surgery translate into cost savings for health care provision.  I suspect the answer to that will also be yes and hopefully translates into increased Bariatric surgery availability through the Public Health system.  Watch this space!  Happy times, Steph Ulmer

Obese people seem likely to live longer if they have bariatric surgery compared to those patients who do not have surgery, according to a paper published in the Journal of the American Medical Association. The study, which included 2,500 obese patients and nearly 7,500 matched controls, concluded that surgical patients had a 53 percent lower risk of dying from any cause at five to 14 years after the procedure.

"We expanded what we've been learning and showed that older men in this study do just as well after bariatric surgery as younger women in previous studies have done," said first author of the report, Dr David Arterburn a Group Health physician and a Group Health Research Institute associate investigator and affiliate associate professor of medicine at the University of Washington School of Medicine. "Previous studies of long-term survival after bariatric surgery involved younger, mostly female populations who tended to have few obesity-related diseases. In contrast, our study's population was older - with a mean age of 52 - and 74 percent male. Also 55 percent of our population had diabetes, and many had other diseases such as high blood pressure, arthritis, heart disease, and depression."

The study was designed to examine the long-term survival in a large multi-site cohort of patients who underwent bariatric surgery compared with matched control patients. In this retrospective cohort study, they identified 2,500 patients (74% men) who underwent bariatric surgery in Veterans Affairs (VA) bariatric centres from 2000-2011 and matched them to 7,462 control patients using sequential stratification and an algorithm that included age, sex, geographic region, body mass index, diabetes, and Diagnostic Cost Group. Survival was compared across patients who underwent bariatric surgery and matched controls using Kaplan-Meier estimators and stratified, adjusted Cox regression analyses.

Seventy four percent of patient had a gastric bypass, 15% sleeve gastrectomy, 10% adjustable gastric banding, and 1% other.

At the end of the 14-year study period, there were a total of 263 deaths in the surgical group (mean follow-up, 6.9 years) and 1,277 deaths in the matched control group (mean follow-up, 6.6 years). Kaplan-Meier estimated mortality rates were 2.4% at one year, 6.4% at five years, and 13.8% at ten years for surgical patients, compared to 1.7% at one year, 10.4% at five years and 23.9% at ten years, for the matched control patients.

Adjusted analysis showed no significant association between bariatric surgery and all-cause mortality in the first year of follow-up (adjusted hazard ratio [HR], 1.28 [95% CI, 0.98-1.68]), but significantly lower mortality after one  to five years (HR, 0.45 [95% CI, 0.36-0.56]) and five to 14 years (HR, 0.47 [95% CI, 0.39-0.58]).

The midterm (>1-5 years) and long-term (>5 years) relationships between surgery and survival were not significantly different across subgroups defined by diabetes diagnosis, sex, and period of surgery.

"We also found evidence that bariatric surgery has become safer," said Dr Matthew Maciejewski, a research career scientist in Health Services Research and Development at the Durham VA and a professor of general internal medicine at Duke University School of Medicine in Durham, NC. "We found that the risk of dying during and soon after bariatric surgery was lower in 2006-2011 than in 2000-2005."

"We have tracked a large group of patients for a long enough time that we can clearly see a strong link between bariatric surgery and long-term survival," added Arterburn. "As time passes, the risk of dying among the patients who've had surgery appears to be diverging from those of the matched controls who haven't had surgery."

With still-longer follow-up, Drs Arterburn and Maciejewski plan to explore various outstanding questions, such as:

• Does bariatric surgery help certain subgroups of patients more or less?
• How long does weight loss last after surgery, and at what level?
• Is the course of associated diseases, such as diabetes, changed?
• And do total costs of health care decrease in the long run?

"Our results may have broader implications for encouraging weight loss in general," Arterburn concluded. "Despite the studies showing that patients with lower BMIs live longer, not much evidence has linked intentional weight loss (from surgery, medication, or diet and exercise) with longer survival. But our results, combined with other studies of bariatric surgery, may help to make that case."

Access to obesity surgery in NZ hampered by lack of understanding

2 February 2015

Hi Everyone, This was from an Obesity Conference at the end of last year and you may agree or disagree with the comments.  I must say from my point of view the attitude of GPs towards Bariatric surgery has changed significantly and for the better since I have been operating regularly in NZ.  That goes for both the Public and Private sector.  Patients generally comment to me that they have discussed the concept of Weight Loss Surgery with their family doctor and the responses are usually positive from their GP.  This is extremely important for me as a Bariatric Surgeon, because my relationship with GPs is a collaborative one.  We definitely work together on the health of my patients from the minute I become involved with their care.  And that is essential, because your GP is the health professional you see most often.  I think this definitely helps patients to achieve the health goals that most come to see me with at their pre-surgery consultation as well!  Anyway, an interesting statement I thought... Steph

Obesity Surgery Society of Australia and New ZealandMonday 17 November 2014, 2:22PM

Media release from Obesity Surgery Society of Australia and New Zealand

One of the most effective long-term forms of treatment for obesity is being denied to thousands of New Zealanders because of a lack of understanding among family doctors about the procedures available, as well as public and private reluctance to fund bariatric surgery, according to the Obesity Surgery Society of Australia and New Zealand (OSSANZ), which will be holding its annual scientific meeting in Wellington this week (November 20th -21st).

The uptake of bariatric surgery in New Zealand is one of the lowest in the world, with less than 900 procedures performed across the entire country last year, which means that around 0.03% of persons who are potentially eligible is having this treatment.

OSSANZ spokesman Dr Jon Morrow, a bariatric surgeon at Auckland’s Middlemore Hospital, says GPs’ lack of understanding about obesity surgery is as much to blame as poor funding for the poor access to bariatric surgery in New Zealand, in spite of the country ranking third in the world for obesity rates.

Dr Morrow explains: `GPs in New Zealand are generally against bariatric surgery even though the evidence is unequivocally in favour of its use. GPs generally tend to be quite traditional in their approach to weight loss, I reckon less than a quarter of GPs here will refer patients for surgery. Diet and exercise are important factors, but there is now a huge amount of data, which demonstrates that for up to 15 years after bariatric surgery people do lose weight and keep it off. Unfortunately in the face of this evidence GPs just continue to do what they have been doing. They see obese patients everyday and just don’t mention it to them because they find it impossible to broach the subject with them.’

Wendy Brown, OSSANZ President and Associate Professor in the Faculty of Medicine, Nursing and Health Sciences at Monash University, Melbourne, adds: `The theme of our annual meeting in Wellington is “working together for the good of our patients”. We know that when diet and exercise intervention has failed for obese patients, bariatric surgery is an effective treatment with a good evidence base. It is important that we educate GPs and the community on the role bariatric surgery may play in the treatment of obesity.

‘Surgery is currently one of the only options available that predictably provides substantial weight loss which is sustained when provided in an environment that supports lifestyle change. We hope that we can raise the awareness of this option for obese persons in New Zealand, and that the community can explore ways to improve access to this surgery.

‘However, bariatric surgery is not a magic bullet. It requires a commitment from the patient to change their lifestyle and to actively participate in long-term follow-up. Therefore, we need to involve GPs and other health professionals to support patients on this journey. It is important we have a team approach in the management of this disease so that we can get the best outcomes for our patients.’

Dr Morrow adds: `Most of the surgery performed in New Zealand is gastric sleeve. This procedure involves removing around 80% of the stomach, leaving behind a small tube of stomach. The part of the stomach that is removed is the area that produces hormones that increase hunger, and on top of this patients are physically not able to eat as much. It is safe surgery, causes less severe nutritional deficiencies in the longer term, has few longer term complications and requires 2-4 follow up visits per year, making it well suited to our population who are often reluctant, or find it difficult to, attend follow-up appointments. Typically, by four years people lose around 60% of the extra weight that they are carrying. With this we see diseases related to obesity such as diabetes, high blood pressure and sleep apnoea improve or completely resolve.

`Yet even though the New Zealand ministry of health knows that there are huge health and economic benefits from bariatric surgery, public and private funding is limited. Procedures cost between $18,000 and $20,000 privately, but the insurance companies will only pay a third of the cost up to a maximum of $8,000 even though it is in their economic interest to reduce the long-term economic effects of untreated obesity.’

According to the World Health Organization someone with a body mass index (BMI) of 30 or more is generally considered as obese. Obesity rates in New Zealand as a whole are just under 30% of the population, but among Maori the rates are over 48% and rise to 68% in Pacific islanders.

Now characterised as an epidemic, obesity in children and adults is associated with serious health risks that include hypertension, dyslipidemia, diabetes, fatty liver disease, obstructive sleep apnea, and psychosocial complications.

Professor Brown points out: `Obesity is a disease with far reaching consequences for health and well-being. Weight loss has the potential to be one of the most powerful health interventions in our community. Whilst prevention would be the ideal, preventative programmes just have not worked so far. Diet and exercise programmes are only successful in the long term for 3% of patients. It is not that obese people are just lazy and can’t be bothered; it is incredibly difficult to lose weight as your body defends your weight vigorously. We believe it is time for New Zealand to look at ways to improve access to bariatric surgery.‘

Psychological factors prevent patients completing surgery

14 January 2015

I thought this was an interesting study that looked at factors that prevented people who qualified for bariatric surgery from actually going ahead with it. Psychological factors are well known to play a part but few studies have actually tried to quantify the effects. I'm sure these factors ring a few bells with some people ie being scared of undergoing major surgery or feeling convinced that they ar able to lose weight themselves with diet and exercise. I suspect that the fact that you are reading this means that you are thinking about Bariatric Surgery as a solution for your own weight problems and I would hate to think that surgery fear would prevent people from being able to take a step that is likely to change your life significantly and for the better!  It is likely that more information may be part of the stepping stones to help you make this type of decision more objectively.  Take a read and let me know what you think. Steph Ulmer

Many bariatric surgery candidates often drop out of the surgical process because they experience surgical anxiety and/or they believe that they can lose weight on their own, without surgery, according to research by investigators led by Dr David Mahony from PsyBari, Brooklyn, New York, US. Although these obese patients present with co-morbidities, these conditions do not sufficiently motivate patients to complete the surgical process.

 “Conversely, factors that are not traditionally assessed in the pre-surgical workup, such as their level of surgical anxiety and their beliefs about their ability to lose weight without surgery, may lead them to decide against surgery.”

The paper, ‘Psychological predictors of bariatric surgery attrition’, published in the open access journal Research, states that an estimated 49-69 percent to that patients who are enrolled in a bariatric surgery programme have the procedure. Previous research has outlined several factors for this high drop-out rate including financial, medical and/or psychological concerns. 

“Given that considerable time, effort, and expense are devoted to pre-surgical screenings, the cost-effectiveness of these screenings may be improved by advancing our understanding of the psychological factors that predict surgical attrition,” write the authors. “Furthermore, if psychological barriers that impede surgical completion can be identified, interventions to manage these barriers could be implemented so that a greater number of patients could receive the benefits of bariatric surgery.”

Study

A total of 123 patients agreed to take part in the study; 105 females (85.4%) and 18 males (14.6%). Of these, 90 (73.2%) identified themselves as Caucasian, 24 (19.5%) as African-American, 7 (5.7%) as Latino, and 2 (1.6%) as “other” race. They had a mean BMI (±SD) of 47.7 (±7.31) and mean age (±SD) of 48.82 (±11.45), when they enrolled in the programme.

The patients were interviewed via a semi-structured clinical telephone interview and their demographic, psychological and medical factors were assessed. All patients were asked about their anxiety about surgical risks, history of weight loss attempts, confidence in their ability to lose weight on their own, presence of obesity related co-morbidities, and their psychological status. Items were responded to with yes/no or rated on a 7 point Likert scale. 

Outcomes

From 122 patients (one patient had missing data), 70 (57.7%) completed bariatric surgery compared with 52 (42.3%) dropped out and did not receive surgery. Of the 70 patients that completed surgery, 31 (44.3%) received the gastric band, 28 (40.0%) received the gastric bypass, five (7.1%) received the sleeve gastrectomy, and 6 (8.6%) received another procedure.

The authors report that those patients who had surgery were more comfortable with surgical risks, had less confidence in their ability to lose weight on their own, felt as though they were less able to control their weight and were more likely to believe that bariatric surgery was the only way for them to lose weight (Figure 1). 

Figure 1. Attrition due to psychological variables (all variables measured on a 7-point Likert Scale and all comparisons p<0.05)

They also had more previous weight loss attempts and were more likely to have experienced weight re-gain after dieting, in the past. No significant differences were found for completers vs. non-completers on medical and/or psychological co-morbidities including type 2 diabetes, hypertension, hypercholesterolemia, sleep apnea, asthma, back pain, heart disease and depression. 

Conclusion

“Overall, these findings offer insights into some of the psychological factors involved in determining whether or not a bariatric surgery candidate completes surgery. Most importantly, the results show that the motivators that patients usually report as their primary reasons for seeking bariatric surgery, such as medical co-morbidities, are not sufficient, the authors conclude. “Conversely, factors that are not traditionally assessed in the pre-surgical workup, such as their level of surgical anxiety and their beliefs about their ability to lose weight without surgery, may lead them to decide against surgery.”

The researchers added that candidates for surgery may benefit from additional education about the severity and potential lethality of their co-morbid conditions, as well as the safety and benefits of bariatric surgery.

The authors also call for future studies to determine whether these barriers are also the reason why so many obese individuals that are eligible for bariatric surgery do not even seek out the procedure.