American Society of Bariatric Plastic Surgeons (ASBPS)

Contact Us |  
[Back to News]

Rational Use of Bariatric Surgery-Physicians' Critical Role in Decision Making

Introduction
Obesity, defined as a body mass index (BMI) of ¡Ý30, is recognized by the World Health Organization (WHO) as a global epidemic.[1] Because there are currently more than 300 million adults who are clinically obese and the prevalence continues to increase (Figure 1),[2] this has become a leading public health concern worldwide.[1,3,4] Severe obesity is a life-threatening disease with numerous comorbidities.



Figure 1.[2]

Obesity is caused by an interaction of many factors, including genetic, metabolic, and environmental factors, as well as cultural, behavioral, psychological, and socioeconomic influences. There is strong evidence to indicate that obesity increases the risk of comorbidities, including hypertension, dyslipidemia, cardiovascular disease, diabetes, some malignancies, respiratory disorders, and mortality.[5,6] Severe obesity is clearly a life-threatening disease.

The risk for morbidity and mortality is proportional to the degree of excess weight in obese patients. According to the WHO, adults with a BMI of 18.5 to 24.9 kg/m2 are considered to be normal weight; those with a BMI of 25 to 29.9 kg/m2 are considered to be overweight; and those with a BMI of 30 to 34.9 kg/m2 are classified as obese class I.[7] Those with a BMI of 35 to 39.9 kg/m2 are considered obese class II, and those with a BMI 40 kg/m2 or greater are considered obese class III or extremely obese.[6,7]

In a recent analysis by Finkelstein et al,[8] the escalating cost of health care for obesity and its comorbidities in the United States across payers ¨C Medicare, Medicaid, and private insurers ¨C including inpatient and outpatient care and prescription drug spending was estimated to be more than 9% of the total US medical expenditures in 1998. This translates to approximately $78.5 billion annually, with approximately half of these costs being paid by Medicaid and Medicare.[9] In a later study by Finkelstein et al,[10] researchers determined that the increased prevalence of obesity was responsible for almost $40 billion of increased medical spending through 2006, including $7 billion in Medicare prescription drug costs. They estimated that the medical costs related to obesity could reach $147 billion per year by 2008. Reducing obesity and its associated comorbidities is of considerable public health importance, and the US Department of Health and Human Services has identified obesity as among the 10 leading health indicators for goals of Healthy People 2010.[6]

Studies show that nonsurgical treatment options for obesity, including diet plans, behavioral modification, exercise, and pharmacologic agents, rarely lead to greater than 10% weight loss in the majority of obese patients.[11] New data also show that for clinically severe obesity (ie, BMI ¡Ý40 kg/m2), bariatric surgery is the most efficacious and enduring therapy.[3]

Newer surgical techniques include laparoscopic gastric bypass, such as Roux-en-Y gastric bypass (RYGB), laparoscopic adjustable gastric banding (LAGB), and biliopancreatic diversion (BPD), either with duodenal switch (BPD/DS) or without (Figure 2).



Figure 2.[3]

Recent data show that the number of bariatric surgical procedures performed each year in the United States is increasing.[3] However, the rate of referral for bariatric surgery is inconsistent. Although primary care physicians (PCPs) and subspecialists see a high proportion of morbidly obese patients, a study by Avidor et al[4] indicated that many of these physicians are unfamiliar with the management of morbid obesity and surgical referral guidelines. Even though these physicians understood the effectiveness of surgical interventions, the referrals for surgery were relatively low. This may be related to physicians' lack of familiarity with appropriate local surgical specialists or facilities. Physicians also may not be aware of their role in the management of obese patients undergoing bariatric surgery and the need for lifelong medical surveillance of these patients.[4]

Recent investigations emphasize the importance of a comprehensive care plan for obese patients who may be candidates for bariatric surgery, including assessment, preoperative and perioperative screening, and long-term postoperative management by an interdisciplinary health care team.[12] A cooperative and proactive effort between PCPs, endocrinologists, and surgical team members is critical in providing optimal patient care and enhancing clinical outcomes.[4,13]

Case/Patient Presentation
Alan is a 56-year-old male bus driver with a BMI of 58 kg/m2. He presents to his PCP, Dr, Jones, an experienced and reputable internist, for his annual physical exam and medication refills. Alan is currently taking metformin, perindopril, and atorvastatin. Dr. Jones notes Alan's morbid obesity and discusses this with him. Alan states that in the past he has only succeeded in losing a little weight using "diets." He has always regained the weight soon after discontinuing the "diet." He has had several weight loss attempts over the past 5 years using several commercial meal programs. Each time he lost 5 to 8 lbs but rapidly regained the lost weight after stopping the program.

Alan's work is sedentary; he is employed as a long-distance bus driver for interstate tours and he spends over 40 hours a week on the road. His spare time is usually spent watching television. He takes occasional short walks but is not physically active, as he is limited by shortness of breath on exertion and he becomes easily fatigued. Alan attempted a physical activity-based weight-loss program 1 year ago, but he could not consistently adhere to the required exercise regimen. Alan's nutrition consists mostly of complimentary take-out and fast food during his long-distance driving.

Social History
Alan is single with no children, and he lives alone. He is close with his extended family living nearby.

Alan smoked tobacco until 12 years ago when he successfully quit by using nicotine patches (now discontinued). He does not consume alcohol or use recreational drugs.

Medical History
Obesity, hypertension, dyslipidemia, type 2 diabetes mellitus (T2DM)

Surgical History
Uneventful laparoscopic cholecystectomy 8 years ago

Current Medications
metformin 1000 mg twice daily
perindopril 4 mg/day
atorvastatin 40 mg/day
Allergies
No known medical allergies

Family Medical History
Father, obese with coronary artery disease, died of a myocardial infarction at age 58.
Mother, age 75, obese, with T2DM.
Brother, age 50, obese, with hypertension and obstructive sleep apnea.

Alan is worried that he cannot lose weight. At his annual exam, Dr. Jones advises him that the main cause of his failure to lose and maintain weight is Alan's inability to follow adequate lifestyle changes. Dr. Jones refers him to both a nutritionist and a behavioral therapist who prescribes a specialized behavior modification and nutrition/lifestyle program. However, because of his sedentary lifestyle and occupation, Alan is unable to adhere to this program, and fails to achieve or sustain any significant weight loss.



Questions answered incorrectly will be highlighted.


Which of the following is not an expected result from improved nutrition and physical activity behavioral modification programs?

Modest sustained weight loss of <5% at 2 to 4 years
Reduced risk of developing T2DM in those with impaired glucose tolerance
A 10% to 20% reduction in total body weight and major improvements or remission in obesity-related comorbidities in well-motivated patients
Failure of sustained weight loss as a result of powerful homeostatic mechanisms that defend weight and adiposity

[Back to News]