ISSUE 3 | DECEMBER 2009 – JANUARY 2010

‘Coffee time with… ’ We talk to Professor John Baxter, President of the British Obesity and Metabolic Surgery Society (BOMSS). 6

Guest InterviewIn this issue we talk to Paul Robinson, Consultant Psychiatrist in Eating Disorders. 8

Assessment of bariatric surgery worldwideFive-year review of bariatric surgery worldwide shows laparoscopic adjustable banding is the most commonly performed procedure. 14

Plus many more...

I N T H I S I S S U E . . . UK primary care practitioners struggle to tackle childhood obesityNew research reveals that practitioners struggle to effectively manage childhood obesity in the UKOver the past few years, the prevalence of childhood obesity has increased and as a result, not only threatens the future health of the nation, but also places a long-term financial burden on an already strained healthcare system. In thE UK, primary care practi-tioners are viewed as having a role to play in the management of childhood obesity. however, some practitioners have questioned if primary care is an effective treatment setting for child-hood obesity, and whether primary care professionals have the resources to deal effectively with the disease. In addition few people have explored in detail practitioners’ views and ex-periences of managing this condition in primary care.

new research, led by Dr Katrina turner from the University of Bris-tol, UK, has assessed primary care practitioners’ views and experienc-es of treating childhood obesity. In a recently published paper, entitled ‘Practitioners’ views on managing childhood obesity in primary care: a qualitative study’ (British Journal of General Practice, 2009), turner and colleagues Drs Julian Shield and Chris Salisbury (University of Bris-

tol, UK), interviewed GPs (n=12), practice nurses (n=10), school nurs-es (n=4) and health visitors (n=4), to explore their views.

turner and her team reported that practitioners felt they could not inter-vene effectively due to lack of exper-tise, resources, and contact with pri-mary school children, the causes of childhood obesity and the need to work with parents.

Department of Health and NICE guidanceIn the UK in 2006, the Department of health produced an obesity care path-way for children and adolescents to be used by primary care practitioners and the national Institute for health and Clinical Excellence (nICE) published guidance on the management and treatment of obesity. the current study showed that many primary care prac-titioners are unaware of this guidance, suggesting that it is unlikely to have a

meaningful impact on the primary care management of childhood obe-sity.

Previous researchers have assessed the views and experiences of primary care

practitioners in treating childhood obesity. however, to date only

two studies have employed qualitative research methods to examine these views and expe-riences in detail. Also, the re-search undertaken so far in this area has been limited to assess-ing only the views of GPs and practice nurses, and was car-

ried out before the publi-cation of the obesity care pathway and nICE guid-ance.

Study resultsAccording to turner, all the participants in the study commented that they were

HEAD-TO-

HEADSleeve gastrectomy staple lines: oversewing vs. reinforcing strips

pages 10 - 11

Continued on page 3

Message from the editorWelcome to the final issue of Bariatric News for 2009. this year has been an important one for the publication. We launched in may and after two issues our readership has grown to almost

2,500 worldwide. We have had the opportunity and pleasure to work with a number of key opinion lead-ers in the field, and have received positive feedback from societies and organisers of national and interna-tional meetings.

In this issue, our cover story discusses the impor-

tant issues faced by UK practitioners when dealing with childhood obesity. mr Paul Super, Birmingham, UK, and Professor Paul Gately have provided com-mentaries on the topic, which you will see on page 3.

on page 4 we have introduced a new ‘Patient Fo-cus’ segment. this segment enables bariatric surgery patients to voice their opinions on the various proce-dures that they have undergone. our first patient dis-cusses his experience with the gastric band.

In our ‘coffee time’ segment (page 6), Professor John Baxter, President of the British obesity and met-abolic Surgery Society (BomSS), discusses the grow-

ing obesity problem in the UK; what he has achieved as President of BomSS; and his current areas of re-search.

Paul Robinson, consultant psychiatrist in eating disorders, is interviewed in our ‘Guest Interview’ seg-ment. he discusses the importance of addressing the psychology behind obesity in order to help patients deal with the repercussions following bariatric surgery. his interview is featured on page 8.

on pages 12 and 13, we examine the obesity, diabetes and hypertension rates in the West and mid-West states of the USA.

We hope you enjoy this issue, which is also the last issue I will be editing before I go on maternity leave. I would like to introduce my colleague owen haskins, who will be managing the publication while I’m away.

melissa Griffithsmanaging editor

If you would like to contribute to the next issue of Bariatric News (March Issue), please feel free to contact Owen at: owen.haskins@e-dendrite.com.

Sayeed Ikramuddin vs. Greg Dakin

ISSUE 3 | DECEMBER 2009 – JANUARY 2010 3BARIATRIC NEWS

concerned about childhood obesity, however, there seemed to be some variation depending on patient population. For example, GPs working in the most deprived areas emphasised that they should address childhood obesity because they had a ‘commu-nity responsibility’.

Some participants believed that primary care was an appro-priate treatment setting for treating childhood obesity, main-ly because it is community-based; because GPs were known to families and could refer patients on to others for further support; and because obesity needed to be addressed before associated clinical complications developed.

One participant explained: “It [childhood obesity] needs to be tackled before the problems arise, otherwise you’re dealing with a child who has clinical problems due to obesity, and we need to be preventing those, we need to be tackling the problem so that those problems don’t arise.”

Primary care as a treatment settingturner explained that GPs, practice nurses, and health visitors were described by themselves and by others as being able to opportunistically mention a child’s weight and provide advice, support, and follow-up. however, some GPs, practical nurses and a school nurse felt primary care was not a suitable treatment setting. they commented that they and other primary care prac-titioners did not have the expertise or time to treat childhood obesity, and had no effective treatment to offer.

One practice nurse said: “I haven’t got the expertise in what to do and what not to do, and the time to do it all.”

A school nurse commented: “We deal with so much with child protection and child and adolescent mental health refer-ring that we have very limited time for health promotion. health promotion is just like the icing on the cake.”

And one GP explained: “I don’t have a way of them losing weight…..I’m motivated to treat things I think I might be able to make a difference with and I think my problem with this is I am not convinced I can make a difference.”

Furthermore, turner noted that GPs argued about the finan-cial aspect of treating childhood obesity in a primary setting. Some felt it was “imprudent” to place treatment in primary care; others believed this would create the wrong mindset among pa-tients.

A practice nurse said: “It’s not an illness they’ve got and it’s a life change that they need to make, so I think they don’t need to see it as a come here, get fixed, and then go back to where they were.”

Some school nurses stated that they could not focus on child-hood obesity because they needed to prioritise child protection and child adolescent mental health.

One explained: “I’ve got a child that’s going into care…I’ve got another child that’s come to me because he’s hearing voices and they’re telling him to do bad things, you have to prioritise those….childhood obesity becomes way down the list.”

Another issue was the limited appointment times available to treat patients.

“I’ve got ten minutes, or I probably haven’t got ten minutes because they have probably come with something else and we have dealt with that and there’s now two mintues left…you are not going to actually have any lasting impact because that’s two minutes against ten years of life.” – commented one GP.

Causes of childhood obesitythe participants described the main causes of childhood obesity as an unhealthy diet and lack of physical activity. these in turn were related to factors that were beyond their influence, such as the availability of junk food, unsafe streets, and a lack of fami-ly cohesion. Some also believed that foods in supermarkets and pre-packed food, easy to cook foods, were also a contributing factor. Safety was another issue, whereby parents would prefer to pick their child up from school rather than have the child walk home from school.

Conclusionsturner and colleagues concluded that primary care can only play a limited role in addressing the current obesity epidemic. For progress to be made, greater effort needs to be in place to ad-dress the causes of childhood obesity and to develop effective interventions that can be delivered outside, as well as within, the primary care setting.

UK primary care practitioners struggle to tackle childhood obesityContinued from page 1

the ReceNt StUdy into practitioner’s per-ception on childhood obesity highlights the problems faced in the UK in dealing with obese children. Whose role should it be to re-educate a gen-eration of young people who are destined to be obese adults of tomorrow? GPs questioned in the study are too busy and few were aware of the NICE guidance on the pathway of care for obese children. As in most areas of healthcare in the UK there are great pressures to treat existing illness and less investment in healthcare preven-tion. Tackling obesity (as a risk factor for fu-ture obesity related illness in later life) is an example of such health prevention measures and GPs are probably not the best individu-als to be doing this.

What this study highlights is the lack of clear strategy and investment in deal-ing with the problem in the preventative set-ting. Current resources in primary care are ill equipped and already stretched to deal with such a massive problem. The obese children of today are destined without intervention to become our most obese cases of tomorrow. Tackling childhood obesity surely must in-volve better education of parents as well as the children themselves.

The existing environment has to change. Strategies towards this goal therefore must encompass education of our entire society

with public education and mass media cov-erage. Perhaps what is really required is hard hitting media coverage which depicts young adults with severe sleep apnoea suffocat-

ing in fat, coverage of multiple adoles-cents self injecting insulin because of type II diabetes and vivid examples of people unable to walk because of their size. Images of young people hav-ing strokes and MIs before their parents would be hard hit-

ting and surely influence those watching. With gradual change there would be some

hope that our infants of the future can be borne into a completely different environment with less exposure to those factors which we all know results in the development of child-hood obesity.

oBeSIty hAS BeeN described as a mod-ern day plague. The findings outlined by Dr Turner provide evidence of some of the chal-lenges associated with addressing this pub-lic health issue. Whilst significant effort has been placed on top level reviews of the obe-sity issue (The Foresight Report in 2007) and a national obesity strategy (Healthy Weight, Healthy Lives 2008), these world leading re-ports have not yet been built upon to ensure effective local strategies and implementa-tion plans are in order to systematically tackle childhood obesity. Given primary care is op-erating at this local level the findings of Turn-er are not surprising. Whilst a few examples exist, namely the award winning strategy de-veloped by NHS Rotherham and adopted by the National Obesity Forum, even this strat-egy requires further development and a na-tional roll out is clearly necessary. In addition, as Turner outlines there is a serious lack of qualitative research at a primary care level to ensure evidence based practice.

A study by Smith et al showed that 75% of healthcare professionals underestimate over-weight children, whilst 50% underestimate the weight category of obese children. This demonstrates a lack of awareness in these key professionals who may seek earlier in-tervention if they were better informed. This is linked to the point that Turner also high-lights that many primary care practitioners are not aware of the availability of effective and evidence based programmes. Our own experience tells us that even if primary care practitioners are made aware of services the referrals from these practitioners are relatively low, thus further work is necessary to support this referral process when evidence based programmes are available.

Despite the shear volume of informa-tion associated with weight management in the media, general press and academic lit-erature, many primary care professionals tell us they require further support and training in terms of the confidences and capabilities to identify and target obesity. This should come as no surprise as there is a lack of training for professionals during their initial training or continued professional development in this area.

Turner also highlights the importance of recognising the additional needs of some. There is clear acknowledgement that obesi-ty is difficult to address as levels of need in-crease and so does the amount of support required. However, this is often not reflected in many local obesity strategies that tend to focus on a ‘once size fits all approach’. The strategy of NHS Rotherham does appreciate the importance of a care pathway that recog-

nises different levels of need so there is evi-dence of good practice.

Turner highlighted the difficulty primary care practitioners face as they attempt to bal-ance their priorities. Often when faced with issues such as child protection or mental health problems, obesity is prioritised as less important as there is no perceived immedi-ate need for action. This demonstrates not an unwillingness of the practitioner but a lack of focus within the system. This is even more important given the overwhelming numbers of children that have a weight problem. Using data from the National Child Measurement Programme, which is now collected annual-ly on 5 and 11 year-old children in England, it is estimated that there are 4.5 million children who are overweight or obese, 2.8 million that are obese and 140,000 that would be de-fined as severely obese in the UK.

Turner's study is helpful as it is provides some well needed clarity. It would appear that there is a lack of clear local obesity strate-gies that are owned by both the Primary Care Trust and Local Authority. There is also a lack of training to support primary care practitio-ners and the care pathway to effective treat-ment based on need is not widespread. Based on these challenges it is unsurprising that primary care practitioners feel that their contribution is not as impactful as they would like it to be. However, it is clear that prima-ry care practitioners are well positioned and can make a significant contribution to tackling childhood obesity if the many barriers to ac-tion were removed.

Comment by Mr Paul SuperConsultant Surgeon, Spire Parkway Hospital and Healthier Weight Centre, Birmingham, UK

Comment by Professor Paul GatelyDirector of Carnegie Weight Management, Leeds Metropolitan University, UK

BARIATRIC NEWS

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2009 Copyright ©: Dendrite Clinical Systems Ltd. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, transmitted in any form or by any other means, electronic, mechanical, photocopying, recording or otherwise without prior permission in writing of the Managing Editor. The views, comments and opinions expressed within are not those of Dendrite Clinical Systems or the Editorial Board.

"What this study highlights is the lack of clear strategy

and investment in deal-ing with the problem in the

preventative setting."

ISSUE 3 | DECEMBER 2009 – JANUARY 20104 BARIATRIC NEWS

“My JOURnEy StARtED in January 2006, when after several attempts to try and lose weight I finally went to see my GP. At this point I was 29.5 stone and suffering terribly from back and knee pain. I was unbelievably depressed as my weight stopped me from doing simple things, such as playing ball in the park with my son, walking to the local shop and even affecting my work. I basically became a cripple. My GP ad-vised me on different options and referred me to a gastric surgeon at the Whittington hospital, London UK.

My BMI at this time was 73 so I was classed as morbidly obese. Between seeing my GP and going to the hospital for my first appointment, I researched all the options given to me by my GP and decided that the gastric bypass was my best option. I was pleased to hear that by my first ap-pointment my funding had been agreed by my primary care trust (PCt) (Barnet, UK) and so the process started.

I had several appointments over the next 12 months seeing different doctors and making sure I was mentally aware of the procedure and to see if I indeed was a suitable candidate for surgery. I

was eventually put on the waiting list in March 2007 with a warning from my surgeon that if I put just one pound in weight on, I would be re-moved from the waiting list. I therefore lost two stone for my surgery.

I was 27 stone at the time of my surgery, which took place on Wednesday 31st October 2007.

the surgery went well and I was sent to the in-tensive treatment unit (ItU) that evening. I was surprised that I was not suffering from a lot of pain and felt that the surgery was the start of a new ‘me’. I was administered fluids for the two weeks after my surgery and then progressed onto soft foods. I lost nearly two stone within six weeks of surgery and the weight just continued to fall.

For the first 12 months I can honestly say that I did not feel any hunger at all but I ate only be-cause I knew I had to. now I can only eat small amounts at a time and some days I can eat slight-ly more than others. I am taking multi-vitamins, iron and calcium supplements every day and I re-ceive a B12 injection every three months from my GP.

the hardest part of my journey has been my

attitude towards food, I still think I can eat the big meals but physically I know I can’t and that is very hard to deal with as a person who used to be able to eat very large portions of food. I do miss food very much and to be honest I have struggled a lot to get my thinking around this fact. I have suffered from dumping syndrome on several oc-casions through trial and error as I discovered what my body could deal with. I am still learning today what I can eat and not eat.

the best thing about my journey is the reac-tion from friends and family I have not seen for a long time, as they cannot believe it is me, and the fact that I can now buy and fit into my beloved Arsenal Football top.

I currently look and feel fantastic and I am asked do I ever regret it. I reply that my only re-gret was not doing it sooner.

I have great admiration for my surgeons (Mr Sufi and Mr heath) and my dietician Mrs. Ella Segaran and last but not least Kirsten McDou-gall, our nurse. I attend the monthly support meetings and am glad to speak to and pass on my experiences to others thinking of having the sur-gery done.

the surgery has given me back my life and gave me a stronger bond with my son as we can do more things together and for me that is the best gift of all.

I will be forever grateful to the team at the Whittington hospital.”

Peter McCarthy

The surgeryFor an obese patient to make the decision to un-dergo surgery in an attempt to loose weight and avoid future obesity-related illnesses, it can be very confusing, confrontational, and frightening. the surgery itself is daunting, however, what hap-pens afterwards can be even more worrying for the patient. they will have to cope with a con-siderable lifestyle change, their relationships may also change, and they may not be able to maintain long-term weight loss. Although Peter is now hap-py that he underwent gastric bypass surgery, he did experience problems during his treatment, and still regularly battles food.

Before Peter decided on which bariatric pro-cedure he wanted, he conducted a lot of research himself. End the end, he chose to have a gastric bypass procedure. he commented, “I did a lot of research via the internet and watching documen-taries on the Discovery Channel, so I had already made up my mind as to which procedure I want-ed. the surgeon recommended that a gastric band would be the best option but I insisted on bypass surgery. After a few tense minutes of giving my reasons he accepted that I would benefit more from a bypass. I decided to have gastric bypass because of my failures with diets before. With a band you still needed to watch what you eat and the amount you eat, for the rest of your life. the band is also reversible, so if you are weak minded (like me) and missed your treats too much you can simply have it removed. Also the success rate with the band compared to bypass was pretty low. With bypass the results are virtually guaranteed. In my case I wanted something permanent and this was my best option.”

Although Peter occasionally suffers from dumping syndrome, he has never suffered from bleeding, ulcers or any other related problems. Overall, he seems to be happy with the entire pro-cess, although he did have some ideas for im-provements. “I feel that people thinking of hav-ing the surgery [gastric bypass] should have more counselling both before and after the procedure, and particularly focus on how their relationship with food will be affected. I feel that from the sup-port group that I regularly attend, this seems to be

the main concern that most people share and need support with. Although I had a terrific dietician, I was not made fully aware of how the surgery would affect my eating habits.”

Peter is now enjoying a more active lifestyle since his surgery two years ago, and no longer suffers from pains in his knees and back when he plays football and other activities with his son. Since the operation, he has become more aware of the wrong and right foods, however, he does admit that his eating habits vary from day to day and his diet is not always healthy. “I would say that I am not eating better but I am eating health-ier as my surgery has stopped me from eating sugary things,” he explained. “My eating hab-its vary but I would say I am enjoying a health-ier lifestyle.”

Relationship with foodWhen a patient decides to undergo surgery to combat their problem with obesity, it is inevita-ble that their relationship with food is affected post-surgery. Some people are capable of ‘retrain-ing’ their minds through various cognitive behav-ioural therapies and other ‘talking therapies’ to change how they feel about food, however, oth-ers still have the psychological attachment to eat-ing the wrong foods and the wrong amounts. Peter explained, “I now feel full after eating but nev-er the satisfying feeling I used to get before the surgery. I sometimes feel nauseous if I have eat-en too much and I have on occasion been sick. Af-ter eating I do become disinterested in food, but only for a short while. I don’t think that even af-ter two years since surgery I have fully trained my mind into thinking I have had enough. I always think I can eat more than I physically can. I still crave food so much and especially all the foods that made me big in the first place and to be hon-est, I don’t think that will ever change, the only thing I can try and change is how to handle those cravings. not easy!”

When asked about why he became obese in the first place, Peter said that it was mainly due to lack of education about food and the affects cer-tain foods can have on weight. “I was affection-ately known as ‘Fat Peter’ within the family, as

there were a few ‘Peters’ and this was the way the family identified us. I was always big and not very active and as I grew older, I just accepted that this was the way I am. After a while I basically just stopped caring.”

he also believes that the food industry should bear some of the responsibility for his weight gain. “I think the food industry has a lot to answer for. they created cheap food that is made readily available through their outlets all over the country, and we all know that this cheap food is designed to appeal to a broad spectrum of people. I know now that these same fast food outlets are trying to tap into the healthy options market, but they will always realise that the unhealthy options will pro-duce the most profits so it will always be available to those who want it.”

there have been some significant movements recently within the fast food industry in the UK to support the public in making healthier choices in an effort to reduce rising levels of obesity and diet-related illness. this was discussed at the nation-al Obesity Forum in October (see page 15). the outcome was that certain food chains will display the number of calories for all their food products, including take-away options. Peter commented, “I am not sure if having calorie information on menus in restaurants will make much difference as I feel that people who go out to a restaurant for a meal do so as a treat and therefore will not take any notice of such information. I have no-ticed some fast food outlets have produced cal-orie information on their products but print them on separate leaflets away from the counter – nev-er on the menus!”

Obesity-related illnessesIt is commonly recognised that many obese peo-ple also suffer from co-morbidities such as type 2 diabetes and hypertension. Peter was a previous sufferer of sleep apnoea but since his operation he no longer suffers from the disorder.

“I have been lucky as I did not suffer from di-abetes or hypertension but I did suffer terribly from sleep apnoea and I was a terrible snorer. this caused endless arguments between my wife and I. She said she would hear me stop breathing while

asleep for anything up to 7–10 seconds. I nev-er noticed a thing. Since my surgery I am happy to report that my snoring has stopped complete-ly (much to the delight of the other half) and my sleep apnoea has cured itself completely.”

The futurehaving surgery to combat obesity is not just sim-ply a ‘quick fix’ option. Patients also have to un-dergo serious lifestyle changes in order to main-tain weight loss in the long-term. Some patients will need ongoing counselling through patient support groups and private psychologists. In addi-tion, most patients will need to take supplements for the rest of their lives. Peter explained, “I don’t know if I will require ongoing help or counsel-ling for the rest of my life but I am happy that help is only a phone call away with Kirsten [bariatric nurse] being available to help in any way possi-ble. Also the support group each month has been fantastic as it helps me to help others, which in a way for me is counselling in itself. As for vitamins and B12 injections, I have been told that I will need to take vitamins and iron supplements for the rest of my life, along with calcium supplements. I have been told that the B12 injections will be ev-ery three months for life, but after speaking to oth-ers at the support group this may not be the case.”

to conclude, we spoke to Peter about his rela-tionship with his son and whether he now believes that educating him about healthier food options is important. “My lifestyle has changed so much for the better and so has my relationship with my son. he keeps telling me how much nicer I look and we do so many more things together now. I feel I have bonded with him more, and I like to think he might be proud of his dad. I try to be responsible with him about what he eats but like any parent, I allow him to have treats every now and then, but he is a very active little boy who is mad on foot-ball. I identify the foods that are bad for him and explain why, using myself as an example.”

Patient Focus

Discussion

Bariatric News up until now has purely focused on technical articles dedicated to the management of obesity and its associated diseases. In this issue, we would like to introduce a new segment that will offer patients who have undergone any surgery the op-portunity to tell their story. We feel that providing this information will help bariatric healthcare professionals to understand how the patient feels throughout their experience, and enable better communication between the patient and multidisciplinary team, there-fore improving outcomes in the long-term.

Bariatric News welcomes Peter McCarthy from Barnet, Herts, UK, who has kindly agreed to share his story….

Weight: 27 stone

Waist: 56 inches

Neck: 22 inches

Chest: 58 inches

Peter’s stats BEFORE SURGERY

Weight: 15.5 stone

Waist: 36/38 inches

Neck: 16.5 inches

Chest: 42 inches

Peter’s stats TODAY

If you have a patient who would like to share their story, please email Owen at: owen.haskins@e-dendrite.com

ISSUE 3 | DECEMBER 2009 – JANUARY 20106 BARIATRIC NEWS

John BaxterCoffee time with

Why did you decide to specialise in bariatric surgery?I had such good results from some preliminary experience with this type of surgery that I de-cided to pursue it. Also there was a gross lack of surgeons with this specialty interest which was also a factor.

Who have been your greatest influences and why?I did not have an early role model but as time went by I was very impressed with Walter Po-iries and his published results in relation to diabetes amelioration. I was also impressed with the professionalism of Nicola Scopinaro and his attempts to develop a new operation to maximise the benefits of bariatric surgery.

What experience in your training has taught you the most valuable lesson?That operating on these patients can rare-ly lead to serious complications and possi-ble death. This confirmed to me the very real need for careful patient selection and particu-larly education of the patients prior to surgery.

Tell us about one of your most memorable surgeries?Operating on a young boy (16) who had un-controllable diabetes, sleep apnoea and type II respiratory failure. He clearly was unlikely to live more than a few more years. He was

one of my early laparoscopic sleeve gastrec-tomies and has subsequently resolved all his co-morbidities. He was subsequently on na-tional television which also helped to highlight the effectiveness of this type of surgery.

What are the biggest challenges facing bariatric surgery?Firstly getting adequate National Health Ser-vice funding to allow a fairer distribution of this treatment to the public. Currently around 50% of all bariatric procedures are performed in private which is not ideal for a socialised healthcare system such as ours. New ideas to allow more NHS funding such as part pay-ment should be considered.

Secondly, there is a need for centres per-forming this surgery to increase their num-bers to drive down complication rates.

Thirdly, although there are good data in existence about the effectiveness of bariatric surgery we need more UK-based data about cost effectiveness.

Fourthly, undoubtedly newer treatments will be developed such as incision-less sur-gery, endoscopic surgery, etc which will bring further pressures to assess their effec-tiveness.

Fifthly, the passionate debate about re-strictive versus bypass surgery needs reso-lution with further studies in the UK. The se-lection of the type of surgical procedure to

perform for a given patient is still a dark art which urgently needs some clarification.

How have you seen the speciality change over the last five years?There has been much more interest from younger surgical trainees in learning to per-form this type of surgery which bodes well for the future. The conversion from open to lap-aroscopic surgery is now almost complete.

How should we tackle the growing obesity problem in the UK? Worldwide?Clearly there needs to be a multifaceted ap-proach to this approach with public educa-tion on the dangers of obesity and more at-tention paid to prevention of morbid obesity development in those who are predisposed. Surgery should always be a last resort and I think some borderline patients could avoid surgery with more public resources being put into non-surgical methods of treatment.

What have you achieved as President of BOMSS (British Obesity and Metabolic Surgery Society), and what do you hope to achieve in the near future?The greatest personal achievement is that of founding the BOMSS which is a good platform for developing the specialty by at-tracting members who are committed to the principles of the society. We have had

roles in training, developing the nation-al database, establishing the NICE guide-lines, establishing the NHS commissioning principles, giving advice to commissioners and other interested parties. We have al-ways run an annual meeting which is well attended and next year will have our first stand-alone meeting. We are also working hard on developing minimum standards for bariatric units which meet our UK require-ments.

What are you current areas of research?I have an active research programme looking into insulin resistance after restrictive and by-pass surgery. We are also interested, as many others are, in the precise method of how by-pass surgery causing almost immediate cure of type II diabetes.

Would you like to make any additional comments?I am due to demit office shortly after sever-al years as a council member. Mr Alberic Fi-ennes (UK) who will take over will bring further skills to building up the BOMSS which has a rapidly rising membership. We are also ex-panding the BOMSS council to get more rep-resentation from members as we have now passed the phase of a fledgling society and now need to mature and take forward the so-ciety’s agenda.

First ever multi-disciplinary group to improve access to treatment for severe and complex obesity in England

The ‘Coffee Time’ segment in Bariatric News is dedicated to the Presidents of national and international bariatric and metabolic societies. Here, we take the opportunity to highlight the important roles of a President, and we allow them to discuss their achievements, concerns and future ambitions of their society. In this issue, we talk to Professor John Baxter, President of

the British Obesity and Metabolic Surgery Society (BOMSS)….

Experts in Severe & Complex Obesity (ESCO) taskforce is launched

A tASKFORCE hAS been set up to pro-mote equitable access and viable funding for the treatment of people with severe or complex obesity on the nhS. the group, called ESCO (Experts in Severe and Complex Obesity) was launched at the national Obesity Forum’s An-nual Conference, held in London in October, and called for action to tackle the current situation.

the group, which combines experts in the fields of surgery, endocrinology, dietetics, psy-chology, gynaecology and health economics, advocates the equitable access to high quality, multi-disciplinary treatment for people with se-vere and complex obesity in England. the group also aims to work towards full implementation of the clinical guidelines issued by nICE in 2006. these guidelines include evidence-based advice on the value in providing treatment with drugs and bariatric surgery.

ESCO will work towards solutions and im-proving outcomes for patients being treated for severe or complex obesity, based on pragmatic, evidence based pathways. With official endorse-ment from influential groups, ESCO will have an authoritative overview for the treatment of the severe and complex obese and will support each group in formulating and promoting its strategy.

nick Finer, Consultant Endocrinologist and Chairman of ESCO announced the group’s plans: “ESCO will advise on long-term solu-tions to improve patient monitoring, standards of care and further research in health econom-ics centred on a multi-disciplinary approach. We aim not only to develop achievable solutions but to change perceptions – that these treatments can put conditions like type 2 diabetes into remis-sion, so weight loss alone should not be just seen as an endpoint.”

the Department of health estimates that around 58% of type 2 diabetes, 21% of heart dis-ease and up to 42% of certain cancers (endome-trial, breast, and colon) are attributable to excess body weight.

Severe obesity is defined by nICE as a BMI

of over 40 or a BMI of 35 and over with an asso-ciated condition, such as type 2 diabetes or high blood pressure. Severe obesity and these associ-ated conditions have huge impact on wider soci-ety. It has been estimated that the cost of obesi-ty to the nhS in the UK is approximately £4.2 billion and it is predicted that this will more than double by 2050. It is estimated that weight prob-lems already cost the wider economy in the re-gion of £16 billion, and that this will rise to £50 billion per year by 2050 if left unchecked.

“Our focus that evidence-based healthcare should reach that severe and complex obese pop-ulation who have explored and tried all alterna-tive solutions but without success,” said David haslam, Chair of national Obesity Forum and ESCO member.

In England, according to nICE, of the 1,010,000 severely and morbidly obese popula-tion, there are currently 230,000 people both el-igible and willing to have surgery. however this year, fewer than 2% of these patients will actual-ly receive treatment.

treating severely obese patients with bariat-ric surgery has been shown to be more cost ef-fective for healthcare systems than the long-term treatment of the chronic obesity-related illnesses such as type 2 diabetes, heart disease and cancer.

Nick Finer

ISSUE 3 | DECEMBER 2009 – JANUARY 2010 7BARIATRIC NEWS

Ethical concerns with paediatric bariatric surgery: Reversing co-morbidities is key “Children and adolescents with morbid obesity are high-risk to remain obese in adulthood,” said Dr Donna Caniano, Ohio State University College of Medicine, OH, US, during her presentation at the Chronic Diseases in Childhood Obesity: Risks and Benefits of Early Intervention Symposium, Columbus, Ohio, US. Her research into ethical concerns and bariatric surgery, found that the primary goal when treating childhood obesity should be to reverse co-morbidities of morbidly obese children and the secondary goal to maintain a healthy weight in the long-term.

Sleeve gastrectomy growing in popularity as primary procedure

“thE DECISIOn tO proceed with bariatric surgery in paediatric pa-tients carries profound ethical burdens for all stakeholders, such as morbidly obese children and adolescents, their parents and families, paediatric physi-cians and surgeons, paediatric healthcare institutions, and society,” said Caniano. “therefore, the decision for bariatric in-tervention should be made only after it is established that the patient’s co-mor-bidities could not be treated with less invasive means, the patient has a favour-able risk/benefit profile, the patient and her/his family have received extensive pre-operative counselling and given in-formed consent, and the paediatric bari-atric team has a comprehensive system of short and long-term care.”

In the US, it has been found that one third of morbidly obese children are so-cially disadvantaged, particularly Afri-can-American girls, hispanic and native American children (Blacksher E Ethi-cal and political challenges to seeking justice. Hastings Center Report 2008; 38:28–35). there are also significant disparities in adults with morbid obesi-ty who undergo bariatric surgery; fewer among African-Americans, hispanics, males and low-income children.

Given this, Caniano explained that society accords parents broad-deci-sion making power for their children, and rarely intercedes in matters of fam-ily choices. She asked, “Could parental

failure to comply with weight reduction either by medical or surgical means be construed as medical negligence?” In re-sponse, she referred to two cases from texas and new Mexico in which mor-bidly obese children were placed in fos-ter care when parents could not maintain calorie reduction diets and weight loss.

Medical communitytoday, the medical community should acknowledge obesity as a global epi-demic, however, medical care is dispro-portionate among groups with healthcare access limitations, said Caniano. In or-der to accept that obesity is now a major healthcare issue, the medical communi-ty will require a new way of addressing paediatric healthcare, such as, defin-ing the roles and responsibilities of ma-jor paediatric professional organisations, and implementing changes in paediat-ric medical education. Furthermore, fo-cusing on prevention, as a key priority should also be part of the medical train-ing strategy, as is identifying the mor-bidly obese and referring them to appro-priate paediatric obesity centres. Also, the establishment of transparent mecha-nisms for review of outcomes, complica-tions, and development of better surgical techniques and operations is a necessary step forward to help provide better stan-dards of care for paediatric patients.

Other medical community ‘responsi-bilities’ include: advocacy at several lev-

els – community outreach, school lunch programmes, and physical education programmes; oversight for bariatric pro-grammes to ensure appropriate patient selection, safety, and long-term care; and to promote basic science and clinical re-search in the prevention and treatment of obesity, explained Caniano.

Healthcare institutionsIn addition, Caniano believes that health-care institutions should be more in-volved in combating childhood obesity. Allocating a provision of adequate re-sources for high quality bariatric servic-es is one issue that should be managed by such institutions. Others include sup-porting innovation and research trials, supporting data collection, growing to be a community leader in weight reduc-tion programmes, and provide full sup-port for the medical community’s efforts for oversight and transparency of results and outcomes.

Paediatric bariatric surgeonsthe role of paediatric bariatric surgeons should uphold the principle of benefi-cence through thorough assessment of metabolic, and cardiovascular co-mor-bidities; as well as uphold the principle of non-maleficence, i.e. Can the adoles-cent patient fully comprehend the risk/benefit profile for a bariatric operation? Additionally, a team approach is neces-sary for assessment of patient maturity

and understanding of the operation, said Caniano.

Informed consentAnother important factor to consider is informed consent. this includes educat-ing the patient and their parents or guard-ians as clearly as possible, when discuss-ing the following:

• Risk/benefit profile• Post-operative compliance and lifestyle• Alternative or no surgical treatment, fi-nancial aspects of bariatric surgery• Short- and long-term follow-up• Candidacy for clinical research trial(s)

Other factors to discuss include:• the irreversible nature of RyGB• Unknown negative consequences of operation in the future• Understanding of what a serious com-plication could mean for the patient• Plan for who will care for the patient during later adulthood• the patient’s ability to retain informa-tion

Role of parentsAccording to Caniano, society as-sumes that parents are in the best posi-tion to make medical/surgical decisions for their child. Society also expects par-ents to be active participants in their child’s healthcare, and expects parents to support necessary dietary and lifestyle

changes for successful post-operative outcomes. “there is an ethical burden of helping a child deal with co-morbid con-ditions, as well as helping them through the extensive pre-surgical evaluation process,” commented Caniano. She add-ed that there is also an ethical burden of helping and understanding the risk/bene-fit profile of bariatric surgery, and an eth-ical burden of decision making for the specific bariatric operation.

Conclusionsto conclude, Caniano explained that the primary goal of treating childhood obe-sity should be to reverse co-morbidities of morbidly obese children and adoles-cents, and the safest bariatric operation should be chosen to accomplish the goal for each individual patient. however, there should be acknowledgement that a surgical option should not be the first line treatment.

A RECEnt SyStEMAtIC re-view of sleeve gastrectomy (SG) as a staging and primary bariatric procedure has shown that it is an effective weight loss treatment for high-risk or super obese patients, also leading to the re-duction in co-morbidities. the review was published in the Surgery for Obes-ity and Related Diseases journal (2009).

In the study, lead author Dr Sta-cy Brethauer, Cleveland Clinic, Oh, and colleagues Drs Jeffrey hammel and Philip Schauer, also from Cleve-land, evaluated the current evidence re-garding weight loss, complication rates, post-operative mortality, and co-mor-bidity improvement after SG.

they explained that the advantages of the SG procedure are that it immedi-ately restricts calorie intake, does not re-quire placement of a foreign body or re-quire adjustments, and can generally be performed in less time than required for bypass procedures. however, the poten-tial disadvantages include irreversibili-ty, increased operative risk compared to other restrictive procedures, and lack of long-term data regarding durability.

Study designAccording to Brethauer, the review was conducted by searching published data using PubMed, and then statistical anal-ysis was performed only on the extract-

ed data from the selected studies). After the initial screening of titles

and abstracts, 2,968 citations were ex-cluded, and 130 studies were reviewed to determine whether they met the in-clusion criteria, explained the authors. Of the 130 studies, 92 were exclud-ed during this phase, and of the 92 ex-cluded studies, 13 were kin studies, sub-studies of a larger series, or duplicate patient groups from the same institution or group. In the end, 36 SG studies, in-cluding 2,570 patients were included in the current analysis. Of the 36 studies, 16 were from Europe, 11 were from the US, three from Asia, two from Austra-lia, two from South America, and one each from Israel and Saudi Arabia. Fur-thermore, 32 studies reported the pa-tient gender (n=2,135), in which 64.5% of the patients were women.

Results: Weight loss and co-mor-bidity reductionAccording to the authors, the mean %EWL after SG was reported in 24 studies (n=1,662) ranged from 33–85%, with an overall mean %EWL of 55.4%. they also found that the mean post-op-erative BMI was reported in 26 studies (n=1,940) and decreased from a baseline mean of 51.2kg/m2 to 37.1kg/m2, post-operatively. “those studies that did not include the %EWL reported the weight

loss in terms of the BMI decrease, the percentage of BMI lost in terms or the percentage of the total weight lost, and all had significant reductions in weight from the baseline values,” stat-ed Brethauer.

In terms of co-morbidity reductions, ten studies provided detailed post-oper-ative co-morbidity data (n=745) with a follow-up period of 1–5 years. the au-thors found that more than 70% of pa-tients in these series had improvement or remission of type 2 diabetes. In ad-dition, significant improvements were seen in the other components of the metabolic syndrome (i.e., hypertension and hyperlipidemia), as well as sleep apnea and joint pain.

Complications and mortalityIt was reported that the major post-op-erative complication rate ranged from 0–23.8%. For studies with >100 pa-tients, the major post-operative compli-cation rates ranged from 0–15.3%, said Brethauer. In 33 studies (n=2,367), de-tailed complication data was provided; including 53 leaks (2.2%), 28 bleeding episodes requiring reoperation or trans-fusion (1.2%), and 15 post-operative strictures requiring endoscopic or surgi-cal intervention (0.6%). Moreover, the overall mortality rate for all studies that reported mortality data (n=2,570) was

0.19%, with five post-operative deaths (within 30 days of surgery), stated the authors. the authors looked specifically at patients who underwent sleeve gas-trectomy as a primary operation in low-er BMI and average risk patients com-pared to a planned first stage operation in high-risk and super obese patients. the high-risk group had a 0.24% mor-tality rate compared to 0.17% in the pri-mary group. the leak rates for the high- risk and primary groups were 1.2% and 2.7%, respectively, and the bleeding and stricture rates were not significantly different between groups. “this study demonstrates that the sleeve gastrecto-my can be performed with low rates of major complications, even in extreme-ly high risk patients and patients with very high BMIs. this is important for patients who may not be good candi-dates for gastric bypass or laparoscop-ic adjustable gastric banding,” stated Brethauer.

ConclusionsSleeve gastrectomy has increasingly gained acceptance among bariatric sur-geons over the past five years, and has become a feasible option in the man-agement of morbid obesity. From the current evidence, it seems that the pro-cedure has proven to be an effective weight loss alternative that can be per-

formed safely as a first stage or primary procedure. “From this large volume of case series data, a matched cohort anal-ysis, and two randomised trials, SG re-sults in excellent weight loss and co-morbidity reduction that exceeds, or is comparable to, that of other accept-ed bariatric procedures,” explained Brethauer. he further concluded that the post-operative major complication rates and mortality rates have been ac-ceptably low. three- and five-year fol-low-up data have demonstrated the durability of the SG procedure, but long-term data with large numbers of patients is limited.

More surgeons are using sleeve gastrectomy as a primary operation as well as a first-stage procedure in high-risk or super obese patients

Donna Caniano

Stacy Brethauer

ISSUE 3 | DECEMBER 2009 – JANUARY 20108 BARIATRIC NEWS

PSyChIAtRIStS, PSyChOLOGIStS AnD other eating disorder (ED) specialists are valuable members of the bariatric multidisciplinary team. Bariatric News recently spoke to Dr Paul Robinson, a consultant psychiatrist in EDs at the Russell Unit and St Ann's hospital, London, and consultant to the Whittington hospital Department of Bariatric Surgery, London, UK, about the psy-chology behind obesity.

Paul Robinson was originally interested in neu-rology before he became interested in psychia-try. he explained, “I became interested in psychia-try when I noticed that men who had suffered heart attacks sometimes had serious problems of adjust-ment. I also was asked to give medical opinions on patients at the Maudsley Psychiatric hospital, and I

decided to retrain as a psychiatrist. My second post at the Maudsley was with Professor Gerald Russell, one of the pioneers in eating disorders psychiatry. he offered me a research post and I spent the next four years in the Institute of Psychiatry and Johns hopkins hospital, Baltimore, with Professor Paul Mchugh, studying the role of gastric satiety in eat-ing disorders.”

When asked how an eating disorders psychi-atrist differs from a general psychiatrist, he ex-plained, “When I first consult a patient who is interested in bariatric surgery, I ask myself the fol-lowing questions:

1. Does this person have an eating disorder? 2. Does he/she have any other psychiatric disorders?

3. What is his/her motivation for surgery? (Includ-ing physical complications of obesity and aesthetic considerations)4. What does he/she know about surgery and its af-termath?5. Why has he/she become obese and developed a psychiatric or eating disorder?

“Once I know the answers to those questions, I can give a reasonable opinion as to what may be re-quired in order to prepare the patient for surgery. the eating disorders psychiatrist is clearly trained to answer questions 1 and 5. Eating disorders psy-chiatrists also have more than average knowledge of medical complications, so may have some more to say on question 3.”

Obese populationsAccording to Robinson, not everyone who be-comes obese has an eating disorder or a psychiat-ric disorder although many may have disordered or at least unwise eating. the most common ED in this population is binge-eating disorder, and a his-tory of childhood or adult trauma is not uncommon in this group.

“Equally a proportion of patients seeking bar-iatric surgery suffer from depression or anxiety, and over-eating may be a response to these mood states,” he said. “In both eating disordered and de-pressed patients, there may be a family history of both problems, as well as obesity, so genetics and, perhaps, childhood experience may contribute. For the rest of the obese population, genetic influenc-es, family norms, reduction in exercise, poor eat-ing habits and free availability of high fat, very tasty foods which many people find irresistible all con-tribute. Looking at how our weight regulating sys-tem may have evolved, early humans had too lit-

tle to eat, and suffered long periods without food. hence we evolved to store calories during times of plenty, and the way they are stored is in fat.”

Psychological care before and after surgeryWe asked Robinson about the importance of psy-chological care before and after surgery. he ex-plained that through the help of the Internet many people are becoming more educated about bariat-ric surgery and its effects. however, this is not uni-versal, and he believes that an adequate educational programme is essential in order to help patients un-derstand exactly what they are going into.

“this can be done by any profession, especial-ly by nurses and dieticians,” he explained. “Where psychiatry and psychology come in is to pick out the patients who are likely to continue bingeing af-ter surgery, and so have a major impact on their outcome. Studies so far seem to show that psycho-logical or psychiatric input prior to surgery has lit-tle effect on outcome. having seen people with pre-operative bingeing or bulimia coming back with pouch dilatation, intractable vomiting and weight gain suggests to me that the proper stud-ies have not been done. Moreover, I have also seen patients with undetected psychiatric disorder pre-operatively coming back more depressed because they have not found another ‘addiction’ to replace their overeating. the worry is that some of those people might turn to alcohol or drugs. More and better research is needed here. My impression is that pre-operative therapy for binge-eating for ex-ample can be very helpful and seems to improve outcome. Post-operatively, we need to be aware of bingeing, which of course will be in smaller quan-tities, as well as depression, and both can be treat-ed, preferably psychologically, but with medica-tion if necessary.”

Addressing the psychology behind obesity is an important step in helping a patient deal with the repercussions following bar-iatric surgery. Many patients seek psycho-logical help before the procedure, how-ever, some believe that it is unnecessary to carry on with treatment once they have undergone surgery. In a number of cases, patients will suffer from depression once the ‘high’ they have achieved from weight loss has worn off as they realise that life’s problems are not just associated with weight. Some also become depressed be-cause they cannot find another ‘addiction’ to replace their overeat-ing, which suggests that the problem is psychological.

Paul Robinson

In this issue we talk to Paul RobinsonConsultant Psychiatrist in Eating Disorders

Guest Interview

Location of excess weight is the key to risk of VTE in obese patients

It hAS BEEn well documented that obes-ity, measured as body mass index (BMI), is associated with VtE. however, little research has looked at the distribution of body fat.

As a result, researchers from Aarhus Uni-versity hospital in Aalborg, Denmark, as-sessed the association between anthropomet-ric variables and VtE. From 1993 to 1997, a total of 27,178 men and 29,876 women aged 50 to 64 years were recruited into a Danish prospective study (Diet, Cancer, and health). During ten years of follow-up, the outcome of VtE events was identified in the Danish na-tional Patient Registry and verified by review of medical records. Body weight, BMI, waist circumference, hip circumference and total body fat were measured at baseline.

the investigators verified 641 incident VtE events and found monotonic dose-re-sponse relationships between VtE and all an-thropometric measurements in both sexes. In mutually adjusted analyses of waist and hip circumference, they found that hip circumfer-ence was positively associated with VtE in women but not in men, whereas waist circum-ference was positively associated with VtE in men but not in women. these anthropo-metric measures were bigger players in ve-nous clotting risk than BMI or weight, the re-searchers said.

Outcomesthe researchers found that every 5cm rise in circumference around the waist was associat-ed with up to an 18% increased risk of deep vein thrombosis and pulmonary embolism in

men. For women, risk rose up to 21% when the added girth was put on around the hips. Of those that were classified by VtE type, 58% were deep vein thrombosis and 42% were pulmonary embolism. however, the relation-ships were the same whether the events were considered idiopathic or provoked by known risk factors (e.g. prolonged travel).

Each of the associations strengthened in an apparent dose-response. For waist circum-ference, the risk was 92% higher for wom-en in the highest category above 92cm, com-pared with the lowest quartile of under 77cm. For men, the risk was doubled for those in the highest quartile compared with the low-est (over 105 versus under 91cm). For hip circumference, the risk was 2.54–fold high-er for women in the top quartile of greater than 110cm, compared with less than 98cm. For men, the risk was lower but still signif-icant at 43% higher for the top versus bot-tom quartiles of over 105 and under 97cm, re-spectively.

the gender differences seen in the study might have been due to high correlation be-tween variables or simply because women tend to accumulate fat on the hips, whereas fat concentrates around the abdomen in men, thus making variation highest and most infor-mative in those locations.

the biological link to venous thromboem-bolism remains unclear, but the group spec-ulated that it could be venous stasis or the fact that fat secrets biologically active sub-stances, including a number with procoagu-lant activity.

AdvertorialWEIGHT LOSS SURGERY AFTERCARE FOR

PATIENTS - HOW CRUCIAL IS IT?the WoRld heAlth Organisation classified obesity as a disease in its own right and this has led to governments and health profes-sionals around the world improving the ser-vices provided to help treat obesity.

The health risks of obesity increase with its severity. Being obese or morbidly obese can cause long-term health risks and reduce overall life expectancy. As well as the medical problems caused by being obese it can also severely affect confidence and self esteem.

Weight loss surgery is becoming more and more popular and is performed to control weight. Weight loss surgery is the first part of a long process, aftercare is the key to suc-cess. Support and guidance is ultimately the one part of the patient journey that truly does make a real difference to their end goal.

Multi-disciplinary teams are key to any surgery provider and are necessary to pro-vide a “gold” standard patient focused ser-vice. To be successful, patients need to have the care, knowledge and skills to work with the surgical procedure they have chosen to have to achieve the maximum weight loss possible. No two patients requirements are the same and everyone has individual needs, hopes and expectations from their surgery, which is why providers need to invest heavily in post-operative resource.

The Weight Loss Surgery Group stand out in a confused marketplace. The group is owned and managed by like-minded, pas-sionate individuals who have many years ex-perience working with weight loss surgery patients. Their multi-disciplinary team offer aftercare to patients who have had surgery

in the UK or abroad. Wendy Stubbs, Bar-iatric Nurse Director, is an expert in the pre and post-operative care of weight loss sur-gery patients and her skills, knowledge, pas-sion, empathy and commitment to the patient is the backbone of their aftercare service.

The group work closely with patients to ‘manage’ their old behaviours because al-though the patient undergoes surgery to band or bypass the stomach their head does not go through the same change and the pa-tient needs to be re-educated otherwise they may fail. If patients are taking the risk of un-dergoing weight loss surgery, they need to ensure that all the other behaviours and their lifestyle in general, are supportive of what they are trying to achieve.

The WLS Group provide surgery includ-ing three years of aftercare and aftercare only packages to patients who have undergone surgery elsewhere.

For more information visit www.wlsgroup.co.uk or call us on 0800 7879029

According to a study, published online in Circulation: Journal of the American Heart Association, although obesity increases the risk of venous thromboembolism (VTE), it is where the excess weight resides that makes the difference.

ISSUE 3 | DECEMBER 2009 – JANUARY 2010 9BARIATRIC NEWS

Since 2000, Helen has worked as a bariatric dietician focusing on patients who have had a gastric band. She believes that the gastric band works beautifully when used correct-

ly, and helps people gain their lives back by control-ling their appetite and enabling them to make better food choices and to lose enough weight to become physically active. Helen's success with this patient group is driven by her passion to help gastric band patients achieve their desired results by offering them an ‘excuse-free’ programme.

According to Helen, the most important fac-tors that contribute to successful patient outcomes in those who have undergone laparoscopic gastric banding are education and support. She comment-ed, “Eating behaviours tend to be unaltered since pre-surgery and can impair the use of the gastric band as an effective weight loss tool. Tackling such eating habits before patients reach the operating ta-ble will improve their chances of successful weight loss after surgery, leaving them with one less ob-stacle to overcome whilst working with their gas-tric band.”

Understanding the gastric band“Patients need to really understand the gastric band and how it works in order to maximise its potential,” stated Helen. “A common misconception is that the gastric band will work like a sleeve gastrectomy pro-cedure and physically force patients to stop eating after consuming a small amount of food. Patients must be made aware that this is not the case.”

Helen feels that a key factor in this may be re-lated to the patient’s perception of portion size, as well as the change in the capacity of their stomach post-operatively. “Patients may misjudge how small the banded stomach actually is. Often I hear ‘It’s the size of a cup’, in fact, the size of the stomach after gastric band surgery varies between individuals, de-pendent on several factors such as the amount of fluid in the band.”

Working with the gastric bandWhen educating gastric band patients on what to eat, it is often difficult to persuade them to follow and stick to guidelines. “Whether someone has a band or not, I believe that the basic weight loss ad-vice is the same: eat a little of everything without counting a calorie or point, including a moderate protein to carbohydrate intake, with a focus on low GI carbohydrates,” explained Helen

Helen finds that often, bariatric patients have been on so many diets that her job is to go back to basics and 'de-medicalise' the process. She states that making a simple, practical eating plan that the whole family can follow is very helpful and then takes this generalised healthy eating approach and makes it “lap band specific”.

Helen’s advice includes:• A discussion of pre-operative dietary require-ments, for example, the Optifast pre-operative diet

for weight loss and liver shrinkage.• A discussion of the initial fluid diet phase imme-diately post-surgery. Helen uses the principle that if you can “liquidise” it and suck it through a straw, it is permitted to “drink your calories”, but this must be nutritionally adequate and should only be used during this period.• The transition to solid food and how to avoid or overcome common problems. • Meal ideas, recipes and individualised plans for the different stages of recovery.

In addition, individuals need support to make permanent life-style changes, as obesity is a chronic condition and will not be cured by a gas-tric band oper-ation, explained Helen. Patients need to “un-learn” the dieting mentality, which will help to re-duce cravings and over indulging which can otherwise become un-controlled due to the feeling of guilt.

Preventing problemsHelen aims to prevent problems before they occur by providing comprehensive advice about some of the most common hurdles that patients may en-counter. For example, certain foods are generally harder to eat, and being aware of this will enable patients to try them at an appropriate time. By eat-ing foods of the correct texture the band will control the volumes consumed during the meal.

Knowing how much food to eat at a meal-time can be an issue, as overeating may cause nausea and vomiting as well as reducing weight loss. Helen compares the optimal meal size to “eating like a tod-dler”. Eating outside meals is also a problem – graz-ing does not promote successful weight loss. This is the case with non-surgical weight loss but also for patients who have had a gastric band as the band resembles a funnel and food can simply continue to slide through.

Patients need to be instructed on how to physi-cally “chew" their food. They may think that 20–30 chews are enough, but it takes more than that. Hel-en’s recommendation for patients is to take no more than one teaspoon of food per mouthful and focus on tasting and enjoying the flavours and textures the food has to offer, before swallowing.

Tightening the gastric bandHelen believes that is important to not overly tight-en the gastric band, allowing individuals to consume normal solid food and not maladapt. Knowing about the correct textures of food will help to manage por-

tion control without needing to counting a single cal-orie.

However, a band that is too loose is also far from ideal. Helen has found that patients do not do well when their surgeon relaxes the band so that they can eat more on holiday or if they are going to a re-mote area and the fluid is removed just in case they encounter any problems.

“The issue here is that the individual has had a good taste of the old days when there was a lot more freedom and they could do what they want-ed, making it hard for them to get back on track and

follow the rules of the banded life essential to suc-ceed. The way I deal with this is by helping patients to remember how they felt when the band was nice-ly tightened and they were not constantly think-ing about food and having to fight

temptation all the time. I promote a slow, gradual in-crease of fluid in the band to allow the individual to get used to eating with the band again, and obvious-ly provide lots of encouragement.”

The gastric band versus gastric bypass debateWhen asked about her position on gastric band surgery compared with gastric bypass surgery, she explained, “Irrespective of the type of surgery cho-sen by an individual, if the patient does not work with the gastric band or gastric bypass by improv-ing their lifestyle, the results will be limited and the patient is likely to be at a greater risk of malnutri-tion. I prefer to not remove anything on a perma-nent basis hence I lean towards the gastric band for this reason.”

Helen’s key tips for successHelen prides herself on her ability to overcome the issue of patients having trouble getting “healthy foods” through their gastric band – by this she means it is preferable to have a band that allows a good volume of “bulky” healthy food options of the right consistency to allow patients to work with their band and obtain the right level of nutrients.

The key to success is ensuring that the individ-ual understands the issues surrounding:• The need to not be stressed.• To choose the most appropriate times to eat more difficult foods, i.e. a steak in the evening when relaxed rather than at lunchtime during a 15 minute break.• If the band site is irritated, then moist, soft foods would be better rather than dry, more solid

foods which could aggravate things further.• The most crucial point is to ensure that the band is not too tight, or life becomes too difficult and people cheat by opting for easier, higher calorie foods for energy.

“I find that the back bone for patient success is having a surgeon who the patient has a good rap-port with and is comfortable seeing regularly, even when they have not lost or perhaps even regained some weight; and having a dietician who provides practical, informative education and support on an ongoing basis, including a support group.”

Helen believes that a multidisciplinary team approach is crucial. This is also strongly recog-nised by the Australian government. Every team should include a dietician, a psychologist, an ex-ercise physiologist, specialist nurses, surgeons and doctors and support meetings to fulfil all pa-tients’ needs. Team members need to have a very good understanding of the complex mind set of this patient group, which often includes elements of food addiction and emotive eating, necessi-tating multidisciplinary treatment to have any chance of success.

Dietary ColumHala El-Shafie is a Specialist Bariatric Surgery Dietician from The Harley Nutrition Clinic in London, and in every issue of Bariatric News she will be speaking to bariatric teams both in the UK and around the globe, bringing you the latest views on nutrition and bariatric surgery.

In this issue, Hala El-Shafie speaks to Australian bariatric dietician, Helen Bauzon, about the importance of education and support for patients undergoing the gastric banding procedure. Helen is also an author, speaker and TV presenter who works independently and with a number of renowned bariatric surgeons in Melbourne. She has recently established a private practice alongside Professor Paul O’Brien's team at the Centre of Bariatric Surgery, and has experience of counselling over 3,000 gastric band patients.

ABOUT HALA...Hala trained as a Dietician at Leeds Metropolitan University completing her clinical training at University College Hospital London. She saw her Dietetic career begin with her first clinical paper in the area of eating disorders being published on graduating. Practicing as a Dietician in both the NHS and the Corporate Sector, Hala was integral in helping to set up the Eating Disorders Service in Manchester. As a specialist bariatric dietician experienced in eating disorders, Hala understands clearly the emotional and psychological attachment often associated with food. Hala practices in London at The Harley Nutrition Clinic in Harley Street. She is also a health writer and is often enlisted to speak and lecture on disordered eating and bariatric nutrition. She is also a member of the Health Care Professional Council (HPC), British Dietetic Association, Nutrition Society and the British Obesity and Metabolic Surgical Society (BOMSS).To contact Hala, please email: info@theharleynutritionclinic.com or call: +44 (0) 207 000 1020 or visit: www.theharleynutritionclinic.com

Helen Bauzon

"I promote a slow, gradual in-crease of fluid in the band to allow the individual to get used to eating with the band again, and obvious-ly provide lots of encouragement."

FOR MORE INFORMATION:If you would like to get in touch with Helen

Bauzon, please contact her on:

info@helenbauzon.com.au or visit her website

www.helenbauzon.com.au

ISSUE 3 | DECEMBER 2009 – JANUARY 201010 BARIATRIC NEWS

HEAD-TO-HEADIn our next issue the debate will be:

Binge-eating disorder is a contraindication to bariatric surgery – yes or no?If you would like to share your views on the current debate, please send your comments to owen.haskins@e-dendrite.com. We will publish your comments in the next issue.

Next issue

hIStORICALLy, thE tyPICAL indica-tions for adjunctive staple line support would be to reduce the incidence of leakage and/or bleeding from the staple line. these are the key outcomes to consider when making a decision whether to utilise buttressing material. the notion that staple line re-inforcement may contribute to a reduced incidence of pouch enlargement has not been entertained and thus will not be further discussed.

Bleeding from the staple line is potentially prob-lematic with sleeve gastrectomy. When this occurs it tends to manifest as a slow and continuous ooze with the associated concern that the resultant col-lection may pose a risk for secondary infection, ab-scess or later contribution to staple line breakdown. Leakage, on the other hand, has far more serious consequences. Leakage can result in a prolonged hospital course requiring drainage procedures, need for stenting, or dilatation of distal narrowing – par-ticularly at the angularis incisura.

An evidence-based review of this topic is not possible with the available data. however, there are a number of theoretical considerations surrounding potential deleterious effects of sleeve reinforcement that are worthy of discussion. these include staple line malfunction and serosal separation, uneven for-mation of the gastric sleeve, persistence of leak, in-creased post-operative adhesions and increased dif-ficulty in converting to a gastric bypass.

Staple line malfunction With sleeve gastrectomy, the risk of staple line malfunction and/or serosal separation is ever-pres-ent. It is important to understand that given the considerable thickness of the stomach between the antrum and the fundus a variety of staple car-tridge heights might be necessary to obtain ap-propriate approximation. Additionally, the added bulk of buttressing material and its inherent in-ability to compress amplifies the already-present risk of malfunction. In the event of staple line dis-

ruption, especially if the sleeve is narrow and the line lies close to the Bougie, extra material with-in the staple line makes oversewing much more difficult. Particularly tortuous areas, at particular risk for compromise, lie at the junction of staple lines whether buttressing material is used or not. Even the most diehard opponent will find it dif-ficult to resist oversewing the staple line in these areas of potential breakdown. Lastly, oversewing can be used to approximate and reinforce the sta-ple line with a precision that simple staple rein-forcement lacks.

Uneven formation of the gastric sleeveAs previously mentioned, multiple staple lines are used to form the vertical sleeve due to varying tis-sue thickness. In spite of creating the sleeve over a Bougie it is still quite difficult to have a perfect-ly uniform tube. Over time, a non-uniform tube can evolve into a rather tortuous pathway with potential

for impeding the passage of solid food as well as the performance of upper endoscopy and the place-ment of a nasogastric tube (should this become nec-essary). Oversewing allows for better sizing of the lumen and better contouring of the sleeve itself. Fi-nally, there is the theoretical concern that the but-tress material may create some rigidity in the staple line that then results in persistent stenosis with sub-sequent nausea and vomiting.

Persistence of leak An additional concern is foreign body contribution to persistent leak. Foreign material has the capac-ity to impede healing and prevent or slow the clo-sure of fistulae until it has completely remodeled or been absorbed. Leaks following gastrectomy occur in a minumum of 1% of patients with the true inci-dence likely higher. the contribution of buttressing in this regard (if any contribution exists) is unclear at this juncture.

Difficulty in reoperative surgery A final observation of ours, which remains untested, is that an increased inflammatory response occurs with prosthetic material and results in increased ad-hesion formation in the left upper quadrant. this re-sponse has been seen with various inert materials including lap bands and sutures. Likewise, exposed staple lines are notorious for producing dense adhe-sions. Anyone re-exploring a patient who has pre-viously undergone a laparoscopic bypass has seen this when examining the gastric remnant staple line. this is particularly relevant when considering those patients who may ultimately need a second stage procedure. In spite of evidence supporting a strong role for the primary use of a sleeve, there continues to be a group of patients who will fail a sleeve and require future conversion. In those patients who un-dergo revision to gastric bypass, one key consider-ation is the potential for staple line failure as the sta-pler comes across the reinforcement at a later date. this might increase the risk of leak and fistula as well as impeding prompt closure.

ConclusionIn the absence of controlled clinical data, the routine use of staple reinforcement has little or no advan-tage over complete staple line oversewing.

Sayeed IkramuddinUniversity of Minnesota, Minneapolis, MN

"In the absence of controlled clinical data, the routine use of staple reinforcement has little or no advantage over complete staple line oversewing."

"Oversewing can be used to approximate and reinforce the staple line with a precision that simple

staple reinforcement lacks."

HEAD-TO -HEADSleeve gastrectomy staple lines: oversewing vs. reinforcing strips

Welcome to our Head-to-Head segment. This is a regular feature where we ask two expert bariatric professionals to debate against each other on a topical issue.

ISSUE 3 | DECEMBER 2009 – JANUARY 2010 11BARIATRIC NEWS

thE MORBIDIty FROM a leak at the gas-tric staple line in sleeve gastrectomy is obviously substantial and is a complication that should be avoided at all cost. the long length of the sleeve gastrectomy staple line, coupled with the variable thickness of gastric tissue, results in significant po-tential for intra-operative and post-operative bleed-ing which can lead to increased operating times, transfusion requirements, morbidity, and hospital stay. Several commercially available reinforcing products have been developed to reduce the risk of these complications. While there are generally no studies that directly compare reinforced staple-lines to those that are oversewn, there are several argu-ments for the use of staple-line reinforcing strips in sleeve gastrectomy. Furthermore, there is evidence that reinforcement with strips may in fact be safer than the alternative of oversewing the staple line. Reduced bleedingthere are numerous lines of evidence that indicate reinforcement of staple lines reduces bleeding, both in sleeve gastrectomy as well as other bariatric op-erations. One study reported on 20 patients who underwent laparoscopic sleeve gastrectomy with or without duodenal switch (Consten ECJ, 2004). Study patients (n=10) had the gastric staple line re-inforced with an absorbable polymer membrane and were compared to non-buttressed (n=10) staple lines. the buttressed group had significantly less bleeding (120ml vs. 210ml, p<0.05), and showed a trend towards decreased hospital stay (3.8 days vs. 4.6 days). In the non-reinforced group there were two staple-line haemorrhages and one patient devel-oped a sub-phrenic abscess. In a poster-presentation at the ASMBS 25th Annual Meeting, another group compared 46 patients with and without staple-line reinforcement (Chiasson PM, 2008) and showed an increase in the number of transfusions required and ICU admissions for bleeding in the non-rein-forced group. Finally, a prospective randomised tri-al of patients undergoing laparoscopic gastric by-pass with and without absorbable reinforcement strips at the staple lines showed a decrease in the number of clips used, higher post-operative haemo-globin levels, and shorter operative time in the rein-forced group (Miller KA, 2007).

Increased tissue strengthWhile the cause of leaks from gastric staple lines is multifactorial, most leaks in bariatric surgery are encountered in the first days following surgery, im-plicating mechanical or tissue-related factors rath-er than ischaemia (Baker RS, 2004). Several studies have shown that staple-line reinforcement can in-crease the strength of staple lines. In one experimen-tal study, pig intestine was divided with and without an absorbable small intestinal submucosa-derived buttress material. the staple lines were subjected to increasing intraluminal pressure by constant in-

fusion of dye until visible leak was seen at the sta-ple lines with the reinforced group showing sig-nificantly higher burst pressures (83 mmhg vs. 53 mmhg) (Downey DM, 2005). In a cadaveric mod-el of stomach staple-lines, absorbable buttress ma-

terial significantly increased the pressure required to cause staple line leakage vs. non-buttressed staple-lines (Baker RS, 2004). Perhaps more importantly, however, this study also looked at the effect of full-thickness oversewing of staple lines. the authors found that oversewing actually weakened all staples lines (p=0.015), though the exact degree of weaken-ing is not mentioned. they also made the observa-tion that the sites of the sutures leaked when the gas-tric pouches were distended by instillation of fluid.

Smaller sleevethere is considerable debate over whether the diam-eter of the sleeve affects weight-loss outcome in ei-ther the short- or long-term. We attempted to look at this in a series of our patients who underwent sleeve

gastrectomy with either a 40F or 60F bougie (Parikh M, 2008). In short-term (12-month) follow-up there was a trend towards greater weight loss in the 40F group, though this did not reach statistical signifi-cance. Other authors recommend the use of an even smaller (32F) bougie and have reported excellent weight loss results out to two years (Lee CM, 2007). We currently use a 40F bougie and “hug” it tightly to ensure a small-sized sleeve. Since we do not ad-vocate routinely oversewing the staple line for fear of causing increased ischaemia, the only option to decrease bleeding with sutures would be via com-

plete imbrication. however this is generally not possible with such a narrow diameter sleeve. the presence of staple-line buttressing material allows us to create a very tight, reproducible sleeve while maintaining excellent haemostasis. there is gener-

ally no need for oversewing or even the placement of haemoclips.

Absorbable buttress materials safeEarly studies of staple-line buttress materials in-volved non-absorbable xeno-materials such as bo-vine pericardial strips, bovine collagen strips, and non-absorbable expanded polytetrafluoroethylene (ePtFE) to prevent air leaks in lung surgery (Mill-er JI Jr, 2001), (Itoh E, 2000), (Fischel RJ, 1998) (Murray KD, 2002). there have also been stud-ies looking at non-absorbable buttress materials in bariatric surgery, particularly gastric bypass (Shi-kora SA, 2003), (Angrisani L, 2004). these stud-ies have reported reduction in staple-line haem-orrhage and anastomotic leaks. however some

complications with non-absorbable reinforcement has been reported, including a report of a patient who had undergone sleeve gastrectomy in con-junction with duodenal switch and vomited small pieces of the buttress material, indicating intralu-minal migration (Consten EC, 2004). there have been no reports of intraluminal migration of but-tress material since the more widespread use of ab-sorbable materials, and reports of complications of any nature are sparse. Furthermore, many of the new buttress materials may serve as a biolog-ic “scaffold” to promote ingrowth of type 1 colla-

gen during the healing process.

ConclusionsButtress materials are not a substitute for sound sur-gical judgment. Staple size must be appropriately selected for the tissue on which it is to be used. this is necessary to allow for proper staple formation while achieving the optimal staple-line strength and tissue compression (Baker RS, 2004). In particular along the thick antrum of the stomach, it may be prudent to forego the reinforcement material with the 4.8mm height of currently available staplers. however, it is clear that staple-line reinforcement has many benefits, including reducing bleeding and increasing the strength of the staple line. these ef-fects may combine to reduce operating time, leak rate, and morbidity. though comparative cost stud-ies are lacking, it is reasonable to speculate that the potential elimination of even one leak might justify the increase in cost of buttress material over the less expensive alternative of oversewing.

References:

Angrisani L, L. M. (2004). The use of bovine pericardial strips on linear stapler

to reduce extraluminal bleeding during laparoscopic gastric bypass: prospec-

tive randomized clinical trial. Obes Surg , 14, 1198-1202.

Baker RS, F. J. (2004). The science of stapling and leaks. Obesity Surgery,

14, 1290-1298.

Chiasson PM, B. S. (2008). Laparoscopic vertical sleeve gastrectomy

(LVSG): efficacy of using Gore Seamguard bioabsorbable staple line rein-

forcement to buttress the staple line. ASMBS 25th Annual Meeting. Wash-

ington, DC.

Consten EC, D. G. (2004). Intraluminal migration of bovine pericardial strips

used to reinforce the gastric staple-line in laparoscopic bariatric surgery.

Obes Surg , 14, 549-554.

Consten ECJ, G. M. (2004). Decreased bleeding after laparoscopic sleeve

gastrectomy with or without duodenal switch for morbid obesity using a

stapled buttressed absorbable polymer membrane. Obesity Surgery , 14,

1360-1366.

Downey DM, H. J. (2005). Increased burst pressure in gastrointestinal sta-

ple-lines using reinforcement with a bioprosthetic material. Obesity Surgery

, 15, 1379-1383.

Fischel RJ, M. R. (1998). Bovine pericardium versus bovine collagen to but-

tress staples for lung reduction operations. Ann Thorac Surg , 65, 217-219.

Itoh E, M. S. (2000). Synthetic absorbable film for prevention of air leaks after

stapled pulmonary resection. J Biomed Mater Res , 53, 640-645.

Lee CM, C. P. (2007). Vertical gastrectomy for morbid obesity in 216 pa-

tients: report of two-year results. Surg Endosc , 21, 1810-1816.

Miller JI Jr, L. R. (2001). A comparative study of buttressed versus nonbut-

tressed staple line in pulmonary resections. Ann Thorac Surg , 71, 319-322.

Miller KA, P. A. (2007). Use of a bioabsorbable staple reinforcement mate-

rial in gastric bypass: a prospective randomized clinical trial. SOARD , 3,

417-422.

Murray KD, H. C. (2002). The influence of pulmonary staple line reinforce-

ment on air leaks. Chest , 122, 2146-2149.

Parikh M, G. M. (2008). Laparoscopic sleeve gastrectomy: does bougie size

affect mean %EWL? Short-term outcomes. SOARD , 4, 528-533.

Shikora SA, K. J. (2003). Reinforcing gastric staple-lines with bovine peri-

cardial strips may decrease the likelihood of gastric leak after laparoscopic

Roux-en-Y gastric bypass. Obes Surg , 13, 37-44.

Gregory F DakinAssistant Professor of Surgery, Weill Cornell Medical College, New York, US

"While there are generally no studies that directly compare reinforced staple-lines to those that are oversewn, there are several arguments for the use of staple-line reinforcing strips in sleeve

gastrectomy."

"Since we do not advocate routinely oversewing the staple line for fear of causing increased ischaemia, the only option to decrease bleeding with sutures

would be via complete imbrication."

HEAD-TO -HEADSleeve gastrectomy staple lines: oversewing vs. reinforcing strips

In this issue, Dr Sayeed Ikramuddin, US, and Dr Greg Dakin, US, debate whether oversewing the staple line is more effective than reinforcing strips in sleeve gastrectomy.

ISSUE 3 | DECEMBER 2009 – JANUARY 201012 BARIATRIC NEWS

A snapshot of

USAPart 1

% of the population

WA OR CA NV AZ NM TX LA AR OK MO KS

Diabetes 7 6.8 8.1 8.1 8.2 7.7 9.3 10 9 10.1 8.2 7.6

Hypertension 25.4 25.5 27.2 26 24.2 24 26.9 30.9 31.5 30.7 29.1 25.6

Obese and overweight children (aged 10-17) 29.5 24.3 30.5 34.2 30.6 32.7 32.2 35.9 37.5 29.5 31 31.1

Prevalence of obesity and overweight adults (aged 55-64) 29.8 29.7 28.3 29.3 29.4 25.1 32.6 35.5 31.9 33.9 33.3 32.9

Prevalence of obesity and overweight adults (aged 65+) 21.6 21 20 18.9 17.6 17.2 21.7 27.3 20 22.5 23.7 21

Obese 25.4 25.4 23.6 25.1 24.8 24.6 27.9 28.9 28.6 29.5 28.1 27.2

Obese and overweight 61.5 61.5 59.7 63.1 61.2 60.2 64.8 64 65.1 65.5 63.9 63.9

Obesity rates in the US are among the highest in

the world, costing the healthcare system billions

each year. According to a recent survey by the Trust

for America's Health and the Robert Wood John-

son Foundation, 25% of adults are now obesse

in 31 states, with two-thirds of adults classed as

overweight or obese. The survey, entitled, ‘F as in

Fat: How obesity problems are failing in America’,

also highlights a worrying trend in children aged

10–17, with some 30% classed as overweight or

obese in 30 states.

In this issue, we will be examining obesity, hyper-

tension and type 2 diabetes rates in the West and

Mid-West states of the US, and in the following is-

sue (Issue 4) we will focus on the remaining East-

ern States.

ISSUE 3 | DECEMBER 2009 – JANUARY 2010 13BARIATRIC NEWS

Diabetes and hypertensionthe report highlighted that obesity and obesity-related diseases such as diabetes and hyperten-sion continue to remain the highest in Southern states, with eight of the ten most obese states in the South. Furthermore, the ten states with the highest rates of diabetes and hypertension are in the South. Adult diabetes rates increased in 19 states in the past year, and in seven states, more than 10% of adults now have type 2 diabetes.

A total of 19 states showed a significant increase in the rates of adult diabetes. West Virginia re-corded the highest rate of adult diabetes at 11.6%, compared with colorado had the lowest rate at 5.5%. the highest rate of hypertension was recorded in mississippi at 34.5%, with the lowest in Utah, at 20.3%. All ten states with the highest rates of hypertension are in the South.

more than 20 million adult Americans now have diabetes, a doubling in the past decade, from 4.8 people per 1,000 to 9.1 per 1,000. A further 57 million Americans are pre-diabetic (at high risk and likely to develop the disease in 5–10 years).

Obesity and childrenIn children and adolescents, the report recorded that nearly 32% are overweight or obese, with approximately 60% of obese children aged 5–10 years have at least one cardiovascular disease (cVd) risk factor and 25% had two or more cVd risk factors.

55–64 years and 65+In these ages groups the report noted that 49 states experienced a significant increase in obe-sity among 55–64-year olds. the rate of growth was lowest in Alabama at 3.4% and highest in oklahoma at 12%. the largest increase was in the state of New hampshire, which experienced a 15.6% increase in obesity rates among adults age 65 and older.

the smallest increase was in hawaii, which saw a 7% rise in obesity rates in a 20-year period (1987–2007). South dakota was the only state with data for all 20 years that did not experience a significant increase.

Recommendationsthe report also includes recommendations for addressing obesity within health reform and calls for a National Strategy to combat obesity. the strategy would define roles and responsibilities for federal, state and local governments and promote collaboration among businesses, commu-nities, schools and families and would seek to advance policies that:

• Provide healthy foods and beverages to students at schools; • Increase the availability of affordable healthy foods in all communities; • Increase the frequency, intensity, and duration of physical activity at school; • Improve access to safe and healthy places to live, work, learn and play; • limit screen time (tV and video games); and • encourage employers to provide workplace wellness programmes.

% of the population

CO UT ID MO WY NE IA MN SD ND AK HI

Diabetes 5.5 5.9 7.2 6.5 6.9 7.4 8.7 5.8 6.6 6.8 6.2 8

Hypertension 21.7 20.3 25.4 24.5 25.2 25.5 28.1 22.6 25.8 25.1 23.9 26.1

Obese and overweight children (aged 10-17) 27.2 23.1 27.5 25.6 25.7 31.5 29.9 23.1 28.4 25.7 33.9 28.5

Prevalence of obesity and overweight adults (aged 55-64) 21.8 30.7 31.7 27.4 28.6 34.1 33.7 32.3 32.3 32.4 35.3 24.1

Prevalence of obesity and overweight adults (aged 65+) 16.4 21.9 20.8 20.4 21.1 23.7 25.4 23.6 22.1 22.3 29.4 13.6

Obese 18.9 22.5 24.8 22.7 24.3 26.9 27.4 25.3 26.9 26.7 27.2 21.8

Obese and overweight 55.3 57 61.7 60.9 61.9 64.2 63.2 62.5 64.9 65.6 65 56.8

Source: ‘F as in Fat: How Obesity Problems Are Failing in America’ - Trust for America's Health and the Robert Wood Johnson Foundation

ISSUE 3 | DECEMBER 2009 – JANUARY 201014 BARIATRIC NEWS

tO UnDERStAnD thE influ-ence and impact of bariatric surgery, it is important to regularly assess the field worldwide. Bariatric surgery has now been recognised as metabolic surgery and it is the state of metabolic/bariatric surgery that needs to be examined, ex-plained Professor henry Buchwald, Uni-versity of Minnesota, Mn, in the recently published paper, ‘Metabolic/Bariatric surgery worldwide’.

In the paper, which was also present-ed at the International Federation for the Surgery of Obesity and Metabolic Disor-ders (IFSO) conference in Paris, France, in August, Buchwald and colleague Dr Danette M Oien, also from the University of Minnesota, Mn, commented that the first global survey of metabolic/bariatric surgery (entitled ‘the IFSO and obesity surgery throughout the world’), was pub-lished in 1998 (Dr n Scopinaro). In 2004, Buchwald and Dr SE Williams, US, pub-lished a five-year follow-up report, enti-tled: ‘Bariatric surgery worldwide 2003’. the recent paper is a subsequent five-year follow-up to the 2003 report and of-

fers a global perspective of metabolic/bariatric surgery over the past ten years.

According to Buchwald, “During the accelerating pandemic of global obesity, certain basic questions are being asked by the medical and the lay communi-ties, as well as government and private funders of healthcare, such as: how many metabolic/bariatric procedures are being performed, by how many surgeons, and where?” he added that since there has been a flux in the types of metabolic/bar-iatric procedures performed, a quantita-tive evaluation of operations completed and existing worldwide trends in proce-dures, need to be assessed.

Study designIn the study, 36 IFSO nations and na-tional groupings were involved, in which 33 responded. the countries included in the national groupings were: Australia and new Zealand, Belgium and Luxem-bourg, and the US and Canada. Sweden, Denmark and norway also participated.

there were two design components to the study; one involved a questionnaire,

which was sent as an email survey and in-cluded the questions:1. Approximately how many bariatric surgery operations are being done in your country yearly?2. Approximately how many surgeons practice bariatric surgery in your coun-try?3. What is your estimate as to the rela-tive percentages distribution of bariatric operations in your country? (Adding up to 100%).

the other component involved data analysis.

ResultsNumber of procedures performed in 2008According to Buchwald, the total number of global bariatric surgery operations was 344,221 for 2008. In 2003, the total num-ber reached 146,301. he explained that the US/Canada grouping performed the majority of operations, totalling 220,000 (103,000 in 2003). Four countries or na-tional groupings performed more than 10,000 operations, including: Australia/new Zealand, Brazil, France, and Mex-ico. A further three countries or national groupings performed more than 5,000 op-erations: Belgium/Luxembourg, Spain, and the UK. Interestingly, Japan and Ser-bia performed less than 100 surgeries (80 and ten, respectively) (table 1).

Number of metabolic/bariatric surgeonsthe global total number of bariatric sur-geons was 4,680, explained Buchwald. the US/Canada national grouping had the majority of surgeons (n=1,625), and

seven other countries or national group-ings had the most surgeons, i.e., more than 100, including: Australia/new Zea-land (n=118), Brazil (n=700), Chile (n=100), France (n=310), Italy (n=300), Mexico (n=150), and Spain n=400).

Types of procedures performedthe most commonly performed pro-cedures in 2008 were laparoscopic ad-justable gastric banding (AGB: 42.3%), and laparoscopic standard Roux-en-y gastric bypass (RyGB: 39.7%), stat-ed Buchwald. he further explained that in 2003, there were no sleeve gastrec-tomy procedures being performed, and in 2008, the number of sleeve gastrec-tomies totalled 5.4% (table 2). note-worthy, over 90% (91.4%) of bariat-ric surgery procedures worldwide were performed laparoscopically.

Global trendsGiven the results, Buchwald conclud-ed that in comparison with the 2003 survey, it appears that all categories of procedures apart from biliopancreatic diversion/duodenal switch, increased in numbers performed. Although, the per-centage of RyGB procedures decreased from 65.1% to 49.0%; whereas, AGB in-creased from 24.4% to 42.3%; and sleeve gastrectomy rose from 0.0% to 5.3%, he explained.

Buchwald also noted that the different world regions varied markedly in their respective five-year trends. “In Europe, though all procedures reported in 2003 increased in numbers in 2008, the relative

percent of AGB decreased from 63.7% to 43.2%, and the relative percent of RyGB increased from 11.1% to 39.0%,” he said. Adding, “though the total number of pro-cedures also increased from 2003 to 2008 in the US/Canada, the trends in the rela-tive percentages of AGB and RyGB were diametrically opposed to those in Europe – AGB increased from 9.0% to 44.0% and RyGB decreased from 85.0% to 51.0%.”

ConclusionsIt appears that, globally, the laparoscop-ic approach to bariatric operations is the preferred method over open sur-gery. Out of all the countries and na-tional groupings that were involved in the study, Buchwald found that the most common procedures were adjustable gastric banding (42.3%), laparoscopic RyGB (39.7%; open plus laparoscopic RyGB 49.3%), and laparoscopic sleeve gastrectomies (5.1%).

According to Buchwald, after con-ducting the survey, new questions were raised, such as 1. Why, in the face of the accelerating world pandemic of obesi-ty and morbid obesity, has the absolute rate of bariatric surgery decreased over the past five years (135% increase), in comparison to the preceding five years (266% increase); 2. Why are there such diametrically opposed trends for lapa-roscopic AGB and laparoscopic RyGB in Europe vs. US/Canada; and 3. Why has sleeve gastrectomy captured 5.3% of the global frequency of bariatric pro-cedures?

“In response to the plateau in the number of bariatric procedures, this phenomenon cannot be explained by an overall lack of patients or exhaustion of the residual patient pool, since we oper-ate on less than 1% of morbidly obese patients worldwide,” said Buchwald. “It is also difficult to believe that only 1% of eligible individuals would elect surgery if it were available to them. the answer, therefore, must be denial of pa-tient access to bariatric surgery by pri-vate or governmental payers for health-care, lack of knowledge of the bariatric surgery option in some communities, misunderstanding about the manage-ment of obesity as a disease, and the continuing underlying prejudice against the obese.”

Furthermore, he believes that the dif-fering operative trends between Europe and the US/Canada could be down to “disenchantment” with AGB in Europe, which has had longer experience than the US/Canada. “Over time, essential-ly all procedures lose some of their ear-ly achieved success and lustre,” Buch-wald commented.

Overall, he suggested that in the fu-ture, in order to increase the accuracy, reliability, and universality of the essen-tial global data, an international IFSO registry should be established.

Assessment of bariatric surgery worldwideFive-year review of bariatric surgery worldwide shows laparoscopic adjustable banding is the most commonly performed procedure

Henry Buchwald

CountryNumber of bariatric surgery

operations 2008*Number of bariatric surgery

operations 2003**

Argentina 2,400 200

Australia/New Zealand 11,914 2,750

Austria 1,741 1,396

Belgium/Luxembourg 8,700 6,000

Brazil 25,000 4,000

Chile 1,500 –

Czech Republic 900 400

Denmark 2,004 –

Egypt 1,500 2,750

France 13,722 12,000

Germany 2,117 1,100

Greece 2,875 500

Hungary 300 30

India 1,216 –

Israel 2,500 1,000

Italy 4,842 3,000

Japan 80 20

Mexico 13,500 2,500

Netherlands 3,500 800

Norway 1,500 –

Peru 600 –

Poland 814 145

Portugal 1,323 –

Romania 837 –

Russia 750 350

Serbia 10 –

South Africa 400 –

Spain 6,000 2,000

Sweden 2,894 600

Switzerland 850 800

Turkey 500 150

Ukraine 190 150

United Kingdom 6,000 600

US/Canada 220,000 103,000

Venezuela 1,242 –

Total 344,221 146,301

Distribution of procedures Percentage 2008* Percentage 2003**

Open adjustable gastric banding 0.1 0.17

Laparoscopic adjustable gastric banding

42.3 24.16

Open vertical banded gastroplasty 0.7 4.25

Laparoscopic vertical banded gastroplasty

0.4 1.18

Open standard Roux-en-Y gastric bypass

5.7 23.07

Laparoscopic standard Roux-en-Y gastric bypass

39.7 25.67

Open long-limb and very long limb gastric bypass

0.8 7.45

Laparoscopic ling-limb and very long-limb gastric bypass

3.1 8.92

Open biliopancreatic diversion 0.3 0.87

Laparoscopic biliopancreatic diversion

0.6 1.09

Open duodenal switch 0.2 2.03

Laparoscopic duodenal switch 0.6 0.85

Open sleeve gastrectomy 0.3 –

Laparoscopic sleeve gastrectomy 5.1 –

Electronic pacer/blockers <0.1 –

Laparoscopic gastric pacing N/A 0.15

Laparoscopic nonadjustable gastric banding

N/A 0.08

Others 0.2 0.06

Total 100.0 100.0

Table 1:Number of bariatric surgery operations being done yearly: 2008 and 2003

Table 2:Distribution of bariatric operations: 2008 and 2003

Source: *Buchwald H, Oien DM. Metabolic/Bariatric surgery worldwide. Obes Surg. 2008. **Buchwald H, Williams SE. Bariatric surgery worldwide 2003. Obes Surg. 2004;14:115 –64.

Source: Buchwald H, Oien DM. Metabolic/Bariatric surgery worldwide. Obes Surg. 2008.**Buchwald H, Williams SE. Bariatric surgery worldwide 2003. Obes Surg. 2004;14:115 –64.

ISSUE 3 | DECEMBER 2009 – JANUARY 2010 15BARIATRIC NEWS

National Obesity Forum 2009: Improving prevention and management of obesity

thE nAtIOnAL OBESIty Forum (nOF) hosted its annual conference in London at the Royal College of Physicians in October. A total of 300 delegates attended the two-day meeting, consist-ing of general practitioners, bariatric nurses, psy-chologists, dieticians and healthcare professionals. Delegates were given the opportunity to take part in discussions with presenters, as well as witness a much-needed debate between food representatives from outlet chains including Pizza hut, Prêt a Man-ger, and Subway. the debate, part of a food label-ling strategy campaign, lead to the agreement that displaying calorie information on all menus is an important step forward for the food industry to help support the public in making healthier choices.

the intensive programme covered many impor-tant topics, ranging from obesity and co-morbidities, the role of testosterone, cancer, psychology of obesi-ty, and childhood obesity. Exciting data was released from Kent primary care trust (PCt) concerning the financial incentive programme that they have com-missioned. the programme also included high pro-file keynote speakers, such as Sir Steve Redgrave, British quintuple Olympic gold medallist rower, who discussed the importance of exercise and weight.

nOF Chair, Professor David haslam comment-ed: “We are delighted with the quality and breadth of the conference which ranged from the terrible con-sequences of sleep apnoea, to the benefits of ‘exer-gaming’ on computers. Feedback has been excellent. next year is our 10th anniversary conference, and we hope to make it the best yet!”

highlights of the nOF 2009 conference are dis-played below.

Obesity and diabetes: GLP-1 receptor agonists show improvements in short- and long-term health outcomes Professor Stephen Gough, Professor of Medicine, Birmingham, explained that obesity is a global health concern affecting over one billion people. he added that in Western countries, in almost 90% of cases, type 2 diabetes has developed due to weight gain. “Around two-thirds of patients with type 2 di-abetes have a body mass index (BMI) of at least 27kg/m2,” he said.

Weight gain is associated with the majority of treatments used in the management of type 2 diabe-tes, as well as been a potential barrier to intensifying treatment. According to Gough, approximately 50% of patients are anxious about weight, and some fear the cosmetic effects of weight gain may outweigh the fear of long-term complications.

Gough then explained the mechanisms of glu-cagon-like peptide-1 (GLP-1), a hormone secret-ed from enteroendocrine L cells of the intestine in response to food. GLP-1 has shown to have an ef-fect on the gastrointestinal and central nervous sys-tem. It delays gastric emptying and causes a reduc-tion in acid secretion, as well as increases satiety therefore suppressing appetite and decreasing food intake, which eventually leads to weight loss. GLP-1-based therapies have shown to have a significant impact on blood glucose control in people with type 2 diabetes.

Exenatide and Insulin GlargineExenatide (Lilly/Amylin) is a GLP-1 agonist has been approved by regulatory agencies as an ad-

junct therapy for patients with type 2 diabetes who are not achieving satisfactory glycaemic con-trol using other hypoglycaemic agents. Gough discussed the outcomes of the Exenatide/insulin glargine crossover trial, in which patients (n=114) were randomised into two groups (Exenatide + Sulfonylurea or Metformin; and Insulin Glargine + Sulfonylurea or Metformin) for 16 weeks, then crossed-over to the opposite group for another 16 weeks. It was found that all patients who were in the Exenatide groups lost weight when those in the insulin groups gained weight.

LEAD programmeLiraglutide (novo nordisk) is the first human GLP-1 receptor analogue, based on the structure of na-tive GLP-1 with pharmacokinetic properties suitable for once-daily dosing. In the Phase II studies and the Phase III Liraglutide Effect and Action in Diabetes (LEAD) programme, liraglutide has been shown to lower glycated haemoglobin A1c to the same degree or more than other oral antidiabetic drugs.

In a review, entitled ‘Glucagon-like peptide-1 and diabetes treatment’, lead author Dr tina Vils-boll, University of Copenhagen, Denmark, and col-leagues discussed the LEAD studies and explained that liraglutide given as a once-daily injection, as monotherapy and in combination with a range of antidiabetic drugs is associated with significant im-provements in hbA1c. Furthermore, in trials of up to one year liraglutide showed maintained weight reduction (up to 4kg in subjects with a high BMI), minimal risk of hypoglycaemia, reductions of up to 3.6mmhg in systolic blood pressure, low and tran-sient incidence of nausea, and negligible antibody formation (Vilsboll et al. 2009).

ConclusionsGough concluded that GLP-1 analogues have prov-en to improve glycaemic control and have been as-sociated with weight loss by effects on the GI system and GLP-1 receptors in the brain.

The role of testosterone in obesityIt has been previously reported that there is a high prevalence of low testosterone levels in men suffer-ing from obesity, metabolic syndrome, type 2 dia-betes and cardiovascular disease. Professor t hugh Jones, University of Sheffield Medical School, and Royal hallamshire hospital, Sheffield, UK, dis-cussed the role of testosterone in obesity, diabetes and cardiovascular disease. he explained that hypo-gonadism is the clinical condition defined as a syn-drome complex which includes both symptoms as well as biochemical evidence of testosterone de-ficiency. “the symptoms are non-specific but in-cludes reduced libido, erectile dysfunction, fatigue, mood changes as well as increased body fat con-tent,” Jones commented. Furthermore, aromatase, the enzyme responsible for metabolising testoster-one to oestradiol, has a high activity within fat, par-ticularly in visceral adipose tissue. “Waist circumfer-ence significantly correlates erectile dysfunction and lower testosterone with worsening severity of erec-tile dysfunction.”

According to Jones, testosterone replacement therapy in men with metabolic syndrome and type 2 diabetes has been shown to improve waist circum-ference and body composition reducing fat and in-

creasing lean mass, but has no overall effect on BMI. he added that testosterone also improves insulin re-sistance, glycaemic control and sexual function in hypogonadal men with diabetes and cardiac isch-aemia in men with angina.

StudyJones then discussed a study by Keating et al., 2006, which included 73,196 men who had cancer con-fined to the prostate. Follow-up took place from 1992–1999. the authors explained that androgen de-privation therapy with a gonadotropin-releasing hor-mone (GnRh) agonist is associated with increased fat mass and insulin resistance in men with prostate cancer, but the risk of obesity-related disease during treatment has not been well studied. they assessed whether androgen deprivation therapy is associated with an increased incidence of diabetes and cardio-vascular disease.

the Cox proportional hazards models was used to assess whether treatment with GnRh agonists or orchidectomy was associated with diabetes, coro-nary heart disease, myocardial infarction, and sud-

den cardiac death. the results demonstrated that GnRh agonist

treatment for men with locoregional prostate cancer may be associated with an increased risk of incident diabetes and cardiovascular disease. they conclud-ed, “the benefits of GnRh agonist treatment should be weighed against these potential risks. Additional research is needed to identify populations of men at highest risk of treatment-related complications and to develop strategies to prevent treatment-related di-abetes and cardiovascular disease.”

Jones also concluded that larger studies are re-quired to determine the longer-term benefit of tes-tosterone replacement therapy.

Obesity and depressionIn an interesting session about the psychology of obesity, Professor Andrew hill, Leeds Universi-ty School of Medicine, UK, discussed how many obese individuals are not only medically compro-mised, but are socially and psychologically disad-vantaged. they can also suffer from low self-esteem and depression.

hill explained that obese women were 17–31% more likely to be currently depressed, 17–53% more likely to have diagnosed depression, and 9–17% more likely to have lifetime diagnosed anx-iety. he added that the risk of depression increases with the level of obesity.

In men, only those morbidly obese or under-weight were at increased depression risk. hill re-ferred to the Swedish Obese Subjects (SOS) surgical intervention trial and explained that the incidence of depression and anxiety decreases with weight loss. “however, at ten years the improvement remained only in those who had maintained 25% or more weight loss. For others, depression was no different to that in the non-surgical controls,” he said.

Additionally, prospective studies show de-pression more than doubles the risk of later obe-sity in adolescent girls. the opposite has been ob-served in older adults: obesity doubles the risk of subsequent depression.

David Haslam Stephen Gough Andrew Hill

ISSUE 3 | DECEMBER 2009 – JANUARY 201016 BARIATRIC NEWS

B y p a s s i n g t h e t i m e w i t h . . . Ian Beckingham

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THE PRODUCT INNOVATIONS that will be pres-ent at the BOMSS Annual Scientific Meeting will include:

Echelon Flex™ Endopath® Stapler:

The novel one-handed design of the de-vice, which builds upon other proven Eche-lon™ Endopath® products with the addition of natural articulation, is intended to provide Bariatric surgeons with improved access during surgery while reducing interruptions. The Echelon Flex™ Endopath® Stapler, de-signed in collaboration with surgeons, is the latest offering from the company’s Echelon™ Endopath® line of surgical stapling products, which provides enhanced system wide com-pression. Understanding tissue dynamics and the effects of surgery upon the tissue is at the foundation of product development at Ethicon Endo-Surgery.

eNdoPAth® Xcel™ with oPtIVIeW™ technology. The first and only universal-seal trocar intended to mitigate trocar-induced smudging, a frustrating occurrence for sur-geons that can cause interruptions during surgery, by minimizing the need for repeated cleaning of the endoscope lens.

Ethicon Endo-Surgery SSL Access Sys-tem: The latest surgical product highlight-ing the Ethicon Endo-Surgery commitment

to advancing minimally invasive surgery with solutions across the continuum of the sur-gical spectrum. The single port access de-vice provides surgeons versatility and effi-ciency for single-site laparoscopy. The SSL Access System consists of two 5mm seals and a larger 15mm seal in a low profile de-sign that allows surgeons to use a wide vari-ety of instrumentation across several Bariatric procedures. Unique to the device is the 360o rotation of the seal cap which enables quick re-orientation of instruments during proce-dures and reduces the need for instrument exchanges.

SAGB Vc Swedish Adjustable Gastric Band with Velocity tm Injection Port and Applier: The SAGB VC innovates on the core heritage of the Swedish Adjustable Gastric Band. It is designed to meet bariat-ric practices' needs by delivering a consis-tent band experience. New features help to simplify band placement and follow-up care for practices and patients.

BARIATRIC EDGE IS proud to be showcasing several novel surgical solutions, at the first British Obesity and Metabolic Surgery Society (BOMSS) Annual Scientific Meeting on the 21st & 22nd January 2010, highlighting how the company is enabling innovation through collaboration across the continuum of surgical techniques and options. First-of-its-kind Trocar technology to improve surgical visualization, a new Access System for single-site laparoscopy (SSL), and an articulating endoscopic linear cutter are among the latest additions to the Ethicon Endo-Surgery portfolio of solutions that respond to the Bariatric surgeon and patient needs.

If you did not have a career in medicine, what type of career would you most like to have and why?Ski Instructor / Mountaineer – I love being in the mountains, hard exercise and outdoor lifestyle – this would provide the perfect job. The physical demands required together with the challenges of the weather with the element of risk never far away.

What posters did you have on your bedroom wall when you were growing up?Olivia Newton John (Take me home country roads single); the girl with the tennis ball (find me a boy in the 70s who did not have that poster on her wall – apparently she was only paid £100 for the picture shoot); and the Sex Pistols (hidden from my mother behind my dressing gown!).

If you could be any animal, what would you be and why?A lion – hanging around in the sun all day; quick run before grabbing lunch and laying about with your friends at the watering hole afterwards – sounds like the Alpine Obesity Surgery meeting!

If you could be any of the following, who would you like to be and why?a. A womanb. Peter Panc. Santa Clausd. A time travellere. Incredible Hulk A time traveller – I would love to go back to the 1950s just after the inception of the NHS [National Health Service]. Rolling up in a Bentley at the hospital with the porter to collect your bags, patients lined up to operate on, lots of nurses and junior staff and no manag-ers and the whole future of laparoscopic surgery to develop. Compare that with our lot now. I’ve never seen the Medical body so dis-enfranchised and disaffected.

The world is about to explode, you have 12 hours to live. What would you do? (keep it clean!)Well – hopefully we would be on the Alpine Obesity Surgery meeting, in which case we would have to miss the scientific meeting for a change, head up the mountain in Kitzbuhl

– ski the greatest run in the world (Run 25 to The Fleckalmbahn at Kirchberg) until we could ski it no more from exhaustion; get lashed at the Brazilian bar, roll on to the Eric Prince bar to watch the finest artistic music video ever and then onto the Londoner to die happy in the knowledge that we had had another of the finest days of our lives.

You are auditioning for X Factor (similar to American Idol in the States), what song would you sing and why?Born to Run (Bruce Springsteen) – great song, great entertainer (met him at dinner after the 1999 concert in Sheffield) still going strong in his 60s – a great role model. Also he can’t sing very well either!

If you could punch one person (a celeb-rity), who would it be and why? Louis Walsh from the X Factor.

‘Ian Beckingham – the Movie’. Who would play you?George Clooney (from ER days) – good looks, nice life style, lovely wife, nice car and oper-ates all day – shouldn’t have to change much to fit into the role then!

Tell us about your funniest medical mo-ment…Watching Roger Ackroyd trying to tie Intra-Corporeal knots. Not without reason is Shef-field known as “The Land of the Extra-Corporeal Knot Pusher”! (p.s. sorry Rog!).

www.obesity-online.com/expertmeeting

ISSUE 3 | DECEMBER 2009 – JANUARY 2010 17BARIATRIC NEWS

Should disordered eating behaviour be a contra-indication for surgery?WEIGht LOSS SURGERy can lead to significant changes in eating behaviour and binge-eating disorder (BED) has been associated with unsatisfactory weight loss in obese patients who have undergone bariatric procedures. At the IFSO meeting held in Par-is, France, Dr Eva Conceicao, University of Minho, Portugal, discussed how eating pat-terns can change after surgery. She also dis-cussed eating problems associated with treat-ment outcomes and the failure of surgery.

In her opening remarks, Conceicao high-lighted two important issues relating to eat-ing disordered behaviour over time and after surgery. She stated that, on one hand, eat-ing disordered patterns seem to change with surgery, causing new eating patterns to arise in many cases. On other hand, it is not clear whether the symptomatology present before surgery is related to failure of the surgical procedure.

Eating behaviour change after surgery“Some studies have shown that BED status seems to disappear and eating behaviours improve with the surgical procedure,” said Conceicao. Citing two sudies, she explained that in one long-term study (13–15 years follow-up), Mitchell et al. 20011, presented weight loss results from a cohort of 100 pa-tients who underwent gastric bypass surgery for morbid obesity.

the mean weight loss at long-term fol-low-up was 29.5kg (range: 13.6 to 93.6kg). It was reported that three subjects weighed more at long-term follow-up than before the operation, although, overall, 74% of those interviewed indicated that the gastric bypass had benefited them in terms of their physi-cal health. however, 68.8% reported contin-ued problems with vomiting and 42.7% with ‘plugging’, and eight had died. the findings in this study suggest that at long-term fol-low-up the majority of individuals who have undergone gastric bypass feel that the proce-dure benefited them, although some compli-cations including difficulties with plugging and vomiting were present at long-term fol-low-up.

In another study by Larsen et al. 20042, short- and long-term eating behavior af-ter laparoscopic adjustable gastric banding (LAGB) and the relationship of binge eat-ing with weight and quality of life outcome were examined. two hundred and fifty pa-tients (221 female, 29 male) completed ques-tionnaires to evaluate quality of life and eat-ing behaviour: 93 patients before LAGB, 48 with a follow-up duration of eight through 24 months, and 109 patients 25 through 68 months after LAGB. the results demon-strated that after surgery, about one-third of the patients showed binge-eating problems, which were associated with a worse post-operative outcome. the authors concluded that, “Eating behaviour improves both short- and long-term after surgery for severe obe-sity. Although LAGB could be a long-term solution to part of pre-operatively eating dis-ordered patients, the identification and treat-ment of post-operative binge-eating appear critical to promote successful outcome after bariatric surgery.”

In a review by Bocchieri et al. 20023, the authors referred to some studies who report-ed a general normalisation of eating behav-iour, i.e., fewer meals, less food consumed at each meal, less eating between meals and less eating in response to strong emotions at 37 months after surgery (Mills & Stunkard, 19764) and a significant decrease in bulimic episodes, secretive eating and hyperphagia at six months after surgery (Crisp et al, 19775).

Conceicao highlighted controversial data, stating that, “Some studies suggest that be-haviours tend to change with surgery (not disappear), and new maladaptive eating be-haviours might develop post-operatively.” In other words, despite an apparent improve-ment in eating behaviours, it is still possi-ble to eat compulsively and some patients

do so although patterns may change due to the surgical restriction. So, given that pa-tients are not physically able to binge eat af-ter surgery, other disturbed and maladaptive eating behaviours seem to appear and result in increased caloric intake. Such behaviour involves grazing and/or continuous snack-ing and consuming larger quantities of sweet foods and liquid or soft foods, which pass quickly through the bypassed stomach. Also, vomiting, plugging and dumping syndrome are new problems that have emerged relat-ed to the surgical procedure and that suggest the presence of problematic eating, said Con-ceicao.

From this, Conceicao concluded that “Since surgery acts as a mechanism of change, it seems that we should start look-ing for a larger range of behaviours not just the ones traditionally diagnosed, and focus on behaviours related to loss of control over eating.”

She added “Also, we have to be more sen-sitive about when we should start screen-ing for these problematic behaviours as the concerning period for re-emergence as mal-adaptive eating behaviours, after an apparent remission and normalisation of eating dis-turbances, seem to appear in the long-term (about two years after surgery), and patients seem to start regaining weight two years or more, post-surgery.”

Eating issues and failure of treatmentMoving forward to the relation between eat-ing behaviours and treatment success, Con-ceicao then explained that some studies relate pre-surgery eating behaviour to poorer out-comes. “Pre-surgical eating disturbances may relate to weight regain following surgery, as they tend to persist or re-emerge post-op re-sulting in poorer outcomes.”

She presented some evidence supporting this, mentioning hsu6, Sullivan and Benotti (1997), who showed that patients undergoing RyGBP with a pre-surgical eating disorder may experience a short-term improvement following surgery, which usually erodes af-ter two years, leading to weight regain. Also, Sallet et al. (2007)7 reported that at two-year follow-up, non-binge-eaters (nBE) (n=33) showed a higher percentage of excess weight loss (%EWL) than subjective binge-eaters (SBE) (n=64; p=0.003) and BED patients (n=34; p=0.001). Conceicao commented that these studies suggest that “the presence of a history of binge-eating prior to treatment is associated with poorer weight loss in obese patients submitted to RyGBP.”

there have also been studies showing that eating behaviour pre-surgery does not dif-ferentiate patients after surgery in relation to different psychological variables or weight regain, and that there are more distinct dif-ferences between the BE and nBE groups before surgery, which are largely impossible to differentiate at post-surgery. As patients show similar outcomes in terms of improved depression scores, binge-eating behaviour, and health-related quality of life regardless of their binge-eating severity before surgery (e.g. Malone, 20048; Green 20049).

According to Conceicao, other studies have shown that only eating behaviours af-ter surgery relate to poor outcomes. She added that despite the impact of pre-surgi-cal binge-eating status on outcome remains to be determined, it is “the development or re-emergence of maladaptive eating-relat-ed cognitions and behaviour (loss of control, disinhibition, etc) after surgery that is more likely related to poor outcomes than binge-eating status prior to surgery.”

In a study that accessed 149 participants at pre-surgery and at least 12-month post-sur-gery, Burgmer et al. (2005)10, showed that pa-tients with a distinct craving for sweets after surgery lost significantly less weight, stated Conceicao. She added, “Patients with binge episodes or ‘grazing’ before surgery did not differ in average weight loss from patients

without binge episodes or ‘grazing’. there-fore, the authors suggested that post-opera-tive, not pre-operative eating behaviour, is of predictive value for the extent of weight loss after gastric restriction surgery.”

Does weight regain mean failure of surgical treatment?Conceicao explained that binge-eaters show a significantly smaller %EWL at follow-up than non-binge-eaters, but they still lose significant amounts of weight after surgery, which leads to many positive psychosocial and life changes. “Data from different stud-ies does not support the idea of exclusion just based on eating disturbances pre-surgery. however, it is important to access eating be-haviours after surgery (monitor the patients progress), particularly in the the long-term (two years after surgery).”

She added that bariatric surgery may be viewed as an intervention that changes binge-eating symptoms and improves most psycho-logical functioning, resulting in a normal-isation of eating patterns, for an important period of time. therefore, research suggests that binge-eating should not be a negative in-dicator for surgery.

Conclusion to conclude, Conceicao said that if eating patterns tend to change after surgery and over time, “It is important to investigate a wide va-riety of maladaptive eating behaviours. the presence of psychological disorders cannot be taken as an absolute criterion for the ex-clusion of candidates for obesity surgery and we should focus on the long-term, when pa-tients need to cope with new eating challeng-es and difficulties.

“It is the ability of the patients to adjust their eating behaviour and their complicance to adequate dietary rules that will determine long-term results.”

References:

1. Mitchell JE, Lancaster KL, Burgard MA, Howell LM, Krahn DD,

Crosby RD, et al. Long-term follow-up of patients’ status after gastric

bypass. Obes Surg 2001;1:464–468.

2. Larsen JK, van Ramhorst B, Geenen R et al. Binge eating and its

relationship to outcome after laparoscopic adjustable gastric band-

ing. Obes Surg 2004; 14: 1111-7.

3. Bocchieri LE, Meana M, Fisher BL. A review of psychosocial

outcomes of surgery for morbid obesity. J Psychosom Res 2002;

52: 155-65.

4. Mills MJ, Stunkard AJ. Behavioral changes following surgery for

obesity. Am J Psychiatry 1976;2:239–43.

5. Crisp AJ, Kalucy RS, Pilkington TR. Some psychological conse-

quences of ileojejunal bypass surgery. Am J Clin Nutr 1977;30:109–

20.

6. Hsu LKG, Sullivan SP, Benotti PN. Eating disturbances and out-

come of gastric bypass surgery: A pilot study. Int J Eat Disord 1997;

21: 385-90.

7. Sallet PC, Sallet JA, Dixon JB, Collis E, Pisani CE, Levy A, et al.

Eating behavior as a prognostic factor for weight loss after gastric

bypass. Obes Surg 2007;17:445–451.

8. Malone M, Alger-Mayer S. Binge status and quality of life after

gastric bypass surgery: a one-year study. Obes Res 2004; 12:

473-81.

9. Green AE-C, Dymek-Valentine M, Pytluk S et al. Psychosocial

outcome of gastric bypass surgery for patients with and without

binge eating. Obes Surg 2004; 14: 975-85.

10. The influence of Eating Behavior and Eating Pathology on weight

loss after gastric restriction Operation.

N E W S I N B R I E F

Waist-hip ratio better indicator of obesity than BMI readings for older adultsNew research by UclA endocrinologists and geri-atricians suggests that waist-hip ratio is a better indi-cator of obesity than body mass index (BmI) readings for older adults. the researchers from the david Gef-fen School of medicine at UclA said that the ratio of waist size to hip size may be a better indicator when it comes to people over 70 years of age. they found that the waist-to-hip circumference ratio was a better yardstick for assessing obesity in high-functioning adults between the ages of 70 and 80, presumably because the physical changes that are part of the ag-ing process alter the body proportions on which BmI is based. the study has been published online in the peer-reviewed journal Annals of Epidemiology (ANI).

AHA supports childhood obesity recommendationsthe American heart Association (AhA) has com-mended the Institute of medicine and National Re-search council for recommending a solid array of meaningful community actions in their new report ‘local Government Actions to Prevent childhood obesity’. With US childhood obesity rates on the rise, youngsters have substantially greater risks for developing and dying from chronic illnesses such as heart disease and stroke in early adulthood. the Association believes it can play a ‘critical role’ in helping children live longer, healthier lives by reach-ing them where they live and play through increased physical activity and improved nutrition. As a re-sult, the AhA will implement many of the report's recommendations such as advancing menu label-ling legislation, implementing safe routes to school, improving nutrition and physical activity in before-and-after school programmes, increasing access to healthy and affordable foods, and making changes to the built environment that increase availability of walking and biking trails and recreational facilities.

Opinions differ over food advertisingResearchers at the International Association for the Study of obesity, based in london, have reported that key players in the argument over advertising junk food to children are unable to agree what should be done. the research reveals deep divisions between eco-nomic interests (the food industry and the advertis-ing agencies) and health interests (consumer groups, family organisations and public health bodies). Senior members of UK national organisations ex-pressed differences of opinion over the strength of the evidence, the likely impact of advertising on children, the value of voluntary measures by the food indus-try and the need for government regulation. ‘Views were deeply split,’ said project director dr tim lob-stein. ‘the opportunities for finding common ground look slim at present, and we urge the government to take a clear lead on how to move the issue forward.’

Study claims obesity causes 100,000 annual cancer cases According to research by the American Institute for cancer Research, obesity causes more than 100,000 incidents of cancer in the US every year. the group, which funds research on the link between diet and the disease, said 49% of endrometrial cancers, which originate in the womb, and 35% of oesophageal cancers are linked to excess body fat. “It’s clearer than ever that obesity’s impact is felt before, during and after cancer, it increases risk, makes treatment more difficult and shortens survival,” said laurence Kolonel of the cancer Research center of hawaii. Researchers have yet to pin down the exact link between obesity and cancer, but some have sug-gested that fat tissue may produce heightened levels of sex hormones that spur cancer growth or that fat lowers immune function.

Eva Conceicao

ISSUE 3 | DECEMBER 2009 – JANUARY 201018 BARIATRIC NEWS

LAPAROSCOPIC TRAINING FOR BARIATRIC SURGEONS – THINKING OUTSIDE THE BOX?

BOMSS HAS GROWN from a small group of en-thusiastic pioneers into a national organisation with its inaugural conference just around the cor-ner. After a long and difficult adolescence, obe-sity surgery in the United Kingdom has matured with surgical units here producing results com-parable to the best centres in the world. Two Brit-ish units have recently been recognised by IFSO as Bariatric Centres of Excellence and there is no doubt that more centres will gain this accredita-tion over the next few years.

Surgical training in the United Kingdom is also going through a period of change caused by the European Working Time Directive and increasing sub-specialisation. In this time of change there may be opportunities for a specialist society such as ours to take the initiative and advance inno-vative training opportunities. The senior bariatric surgeons of today have learnt their craft through hard won lessons that come with experience, but how are next generation of “metabolic and obesi-ty” surgeons to be trained?

There are currently very few formal NHS train-ing programmes in bariatric surgery in the Unit-ed Kingdom. Trainees with an interest in bariat-ric surgery must hope that they find themselves in the fortunate position of working in a recog-nised NHS bariatric centre, attend courses that give a flavour of the field or arrange for ad hoc periods of mentorship and training from experi-enced surgeons. However, it is clear that in order to attain an adequate standard of surgical exper-tise, those who wish to become the bariatric sur-

geons of tomorrow must be prepared to invest a considerable period of time to hands-on train-ing in recognised high volume centres that prac-tise bariatric surgery to the highest standards. But how?

In recent years a number of formal fairly short-term bariatric fellowships have been introduced such as the BOMSS-administered scheme sponsored by Ethicon Endosurgery Ltd. With NHS-funded bariatric training posts so scarce, this collaborative approach with industry may create an opportunity to harness private sector funding for surgical training. The scheme run by our organisation Gravitas, is another good exam-ple of how beneficial this kind of innovative ap-proach can be. Gravitas (who were awarded the prestigious Association for the Study of Obesi-ty award for best practice in obesity care earlier this year) is a bariatric surgeon-led collaborative treating both NHS and private patients. It was es-tablished with the aim of creating self-financing, highly sub-specialised bariatric units within the UK (similar to that seen in Europe and the USA), which run in parallel and in partnership with the NHS, preserving the key aims and functions of a high volume teaching hospital department and retaining research and training at its core.

The Gravitas FellowshipThe Gravitas Fellowship was introduced in 2007. It aims to provide senior surgical trainees with firsthand experience and training in advanced laparoscopic bariatric surgery in a well-estab-lished multidisciplinary environment. Through one-to-one teaching in theatre, graduates of the Fellowship are expected to leave with the ability to practise independently as bariatric surgeons on completion of the training programme, confi-dent in performing gastric banding, laparoscopic gastric bypass and sleeve gastrectomy. Fellows are also exposed to more complex work such as

duodenal switch and revisional/endoluminal sur-gery, but despite the heavy theatre schedule (up to seven bariatric operating sessions per week), a key element which is constantly reinforced dur-ing their training is the importance of the acqui-sition of non-operative skills essential for safe patient selection and the management of post-operative problems both routine and esoteric.

Fellows are expected and encouraged to per-form clinical research and contribute to ongoing projects within the department with a view to pre-sentation of their work at national and internation-al meetings. During 2009, as well as presenting at AUGIS, ASGBI and various specialist meet-ings, Gravitas Fellows attended the International Federation for Surgery of Obesity meeting in Par-is to deliver no fewer than twelve presentations, more than any other single unit worldwide.

Now in its third year, the Gravitas Fellowship has provided comprehensive training for two (now well-established) bariatric surgeons and a further senior trainee. As a financially indepen-dent organisation, Gravitas benefits from a flexi-bility in decision-making which is often impossible in larger organisations such as NHS Trusts. This has allowed us to reinvest profits and increase the number of bursaries available in 2009/10 to fund between two and four full time trainees per year during the final year of their pre-consul-tant training. The duration of training funded by the bursaries varies from 6–12 months depend-ing on previous experience. Our current Fellows have performed in excess of 220 level 3 major bariatric procedures this year (often as first op-erator) in addition to assisting in more complex revisional surgery cases. The next round of Fel-lowships for 2010/11 will be advertised in early summer and we would invite all potential candi-dates to contact current and past Fellows for fur-ther information, or visit our website at www.gravi-tas-ltd.co.uk.

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Conor J Magee , Jonathan Barry

Rob Macadam

David Kerrigan *

Gravitas Bariatric Surgery Ltd

* to whom correspondence should be addressed

T: +44 151 929 5407

F: +44 151 929 5410

E: david.kerrigan@gravitas-ltd.co.uk

January 21– 22 British Obesity and Metabolic Surgery Society (BOMSS)Croydon, London

T: +44 (0)20 7973 0301

F: +44 (0)20 7430 9235

E: shopwood@asgbi.org.uk

W: www.british-obesity-surgery.

org/2010conference

March 14–17 8th International Obesity SurgeryExpert MeetingSaalfelden, Austria

T: +43 664 4027645

E: g.wesely@sbg.at

W: www.obesity-online.com/Expertmeeting

June 20–25 27th Annual Meeting of the ASMBSLas Vegas, NV

T: +1 352 331 4900

F: +1 352 331 4975

E: info@asmbs.org

W: www.asmbs.org

July 11–15XI International Congress on ObesityStockholm, Sweden

T: +44 20 7467 9610

F: +44 20 7636 9258

E: ico2010@iaso.org

W: www.ico2010.org/contact

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