A comprehensive obesity strategy is acutely needed in the UK. The government’s new strategy might not be such good news for people who are struggling with weight problems, however, if it follows in the footsteps of previous strategies, which have focused on prevention but have failed to tackle how existing obesity cases should be treated.
Obesity is not what the media, the majority of the public, many healthcare professionals sufferers think. This tends to be along the lines of assuming that it stems from a failure of willpower, and can be reduced to an equation of eating too much and exercising to little. The latter view is the result of weight bias, a problem that affects our country worse than many others in the West.
Instead, obesity must be thought of as a complex disease that has several genetic, hormonal, environmental, microbial, dietary and psychological causes. The interaction of those factors has resulted in the current epidemic, with an estimated 12 million people affected in the UK.
Treatment is highly complex. Any treatment for obesity should meet at least one of five criteria (preferably all of them) to be considered effective. First, it should help people to lose substantial weight and maintain the weight loss. Secondly, it should help sufferers to have their condition and associated complications cured, the control of the condition improved, or the occurrence prevented. Thirdly, it should prevent people with obesity from dying young. Fourth, it should improve people with obesity’s quality of life. Finally, it should not be too expensive – preferably, it should result in money being saved.
The options available for treatment in the UK are: dietary, lifestyle and behavioural interventions; medications (currently Orlistat is the only licensed medication for obesity); and bariatric surgery.
When the three types of treatment are compared in well-designed studies, bariatric surgery achieves much better outcomes than medications or dietary and lifestyle interventions, taking account of those five criteria.
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Weight loss achieved by dietary, lifestyle and behavioural interventions averages at about 2-3%. Most patients who diet put the weight they lost back on within the first 12-18 months after the intervention. Currently licensed medications are slightly more effective, but still usually achieve only a less than 5% reduction, with many patients putting the weight back on when the treatment is stopped. In comparison, bariatric surgery achieves substantial weight loss in the short term (over 30%) and in the long term (average weight loss in patients who undergo gastric bypass is 28%, even 15 years after the surgery).
In addition to its powerful capacity to reduce weight, surgery also achieves much better outcomes with regard to resolving the complications attached to obesity. For example, around 70% of patients who are obese and diabetic will achieve remission of their diabetes if they undergo bariatric surgery. It reduces the incidence of deadly heart attacks and strokes by 50%, and successfully prevents other obesity-related conditions from occurring. For example, it reduces the development of cancers in obese females by 50%. The incidence of diabetes is four times lower in diabetic and obese people who undergo the surgery compared to those who do not.
The benefits from the substantial weight loss that can be achieved, and the cure, prevention or improvement of related conditions both result in significant increased longevity. The proportion of whose who have undergone surgery who die within the first 15 years after the intervention is reduced by 25%.
Furthermore, several indicators of quality of life improve. The cost of a surgery is relatively small (around £7,000), and the cost to the NHS will be recovered by savings on care for other associated conditions further down the line. It is also very safe – the risk of complications is small and the risk of dying within the first 30 days after surgery in the UK is less than 1 in 500 patients. This is lower than the risk of dying with other operations which are performed much more commonly, including gallbladder removals and hip replacements.
There are more than 2 million people who qualify for bariatric surgery in the UK under the National Institute of Clinical Excellence’s qualifying criteria. However, only 5,000 operations happen every year in the NHS. This is one of the lowest numbers of bariatric operations relative to the population in the Western world.
What is the reason for this low number? There are many hoops that patients need to through to get the surgery. Many patients with obesity do not get referred by their GPs to weight management services. This is in part caused by weight bias and by a lack of obesity education and training, both in medical schools and after graduation. In addition, most parts of the country do not have weight management services that the GPs can refer the patients to.
It is mandated that patients are referred to a non-surgical weight loss programme (called tier 3) before being referred to bariatric surgery. Engagement with the service for several months and achieving some weight loss (about 5%) are imposed as conditions that have to be met before the patient can be referred. Many feel disillusioned and struggle with this mandatory pre-surgery programme.
Weight loss programmes offer dietary, lifestyle and behavioural interventions that most patients with obesity have already tried in the past but which result either in little or no weight loss or in no maintenance of the reduced weight. They might not be able to attend sessions held during working hours and may not be able to attend regularly, meaning many are unable to lose weight with the programme. Perceived poor engagement, or failure to achieve weight loss targets, are some of the excuses used not to refer patients for the operation.
If the government really wants to create an effective obesity strategy, it must be bold and embrace the most clinically and cost-effective treatment. It must remove the obstacles put in front of obesity sufferers to reduce their access to effective treatments. It should mandate every clinical commissioning group (CCG) to have a clear referral pathway to weight management services, including, bariatric surgery, and should incentivise GPs to refer more patients and hospitals to perform more operations.
A modest increase of bariatric operations from 5,000 to 20,000 would still mean fewer surgeries in the UK compared to countries of similar size – France conducts 60,000 publicly funded operations a year. Even this, however, would help an extra 15,000 people with obesity to change their lives for the better. The £100 million cost – at least partially recoverable – is a low price for giving 15,000 people a chance to live better, lighter and longer lives. It is a price worth paying.
Mr Zaher Tuomi is a consultant bariatric and upper gastrointestinal surgeon.