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special section: obesity Bariatric Surgery Increases Longevity By Adrian G. Dan, <strong>MD</strong> The field of bariatric surgery has grown considerably since operative procedures were first performed with the intent of weight loss in 1956. The next fifty years have witnessed an obesity epidemic that has reached global proportions and is threatening to decrease the average life expectancy of future generations. This growing demand and the explosion of new technologies brought about by the laparoscopic revolution have resulted in the perpetual improvement of surgical techniques, leading to an exponential increase in the volume of patients undergoing such weight loss procedures. Bariatric surgeons have observed first hand the direct impact that bariatric surgery has on the quality of life of morbidly obese patients. In addition, the health benefits became evident as resolution of medical co-morbidities associated with the metabolic syndrome consistently followed weight loss. Researchers around the world reported improvement and resolution of type 2 diabetes, hypertension, hyperlipidemia, obstructive sleep apnea, and GERD, amongst many other conditions. Surgical weight loss has distinguished itself as the only dependable long-term weight loss solution for patients with morbid obesity. Despite these significant benefits, there had been little hard scientific evidence thus far demonstrating any survival advantages. Recently, however, several studies have begun to clarify the impact that weight loss surgery has on the survival and longevity of morbidly obese patients. Studies from Canada, Sweden, Australia and Italy have shown a significant survival benefit for patients undergoing weight loss operation, when compared to non-surgical control groups. These patients underwent a variety of procedures, including gastric bypass and laparoscopic adjustable gastric banding. The most recent evidence, published in the New Studies from Canada, Sweden, Australia and Italy have shown a significant survival benefit for patients undergoing weight loss operation, when compared to non-surgical control groups. England Journal of Medicine, is an elaborate study from the University of Utah spanning a 19-year period. This large retrospective cohort study, investigating the effects of Roux-en-Y gastric bypass, found that the long-term mortality after just seven years of mean follow-up was lower by 40% in the surgically-treated patient group. Specifically, mortality was reduced by 56% from coronary artery disease, by 92% from diabetes-related causes and by 60% from cancer-related causes. This avalanche of scientific data substantiates the survival advantage that bariatric surgeons have observed in patients who have chosen weight loss surgery as a means to improve their overall health. As more evidence is gathered regarding the safety, health benefits and survival advantages provided by weight loss surgery, more patients are likely to pursue the health benefits and increased longevity conferred by bariatric surgical procedures. Dr. Adrian Dan is with Summa Physicians, Advanced Laparoscopy Surgery of Northeast Ohio. He is also an assistant professor of Surgery at Northeastern Ohio Universities College of Medicine and serves as Associate Medical Director of the Bariatric Care Center – Summa Health System. ■ 1 6 | GREATER AKRON/CANTON M.D. NEWS JANUARY-FEBRUARY 2008
feature Obesity: The Continued Battle By Liz Meszaros Approximately 15 million people in the United States — that’s one in 50 adults — are morbidly obese, according to data from the American Society for Metabolic and Bariatric Surgery (ASMBS). Morbid obesity is defined as a body mass index (BMI) of 40 or more, or a BMI of 35 or more with an obesity-related condition, such as type 2 diabetes. Morbid obesity is considered by the American Society for Metabolic and Bariatric Surgery as a life-threatening disease. The comorbidities and illnesses associated with morbid obesity are numerous, and include type 2 diabetes, coronary heart disease, stroke, hypertension and almost all types of cancer. They also include asthma, osteoarthritis, joint degeneration, gastroesophageal reflux disease, chronic headache, liver disease, sleep apnea, lower back pain and urinary incontinence. Professional medical institutions are well aware of the costs and effects of obesity and morbid obesity. For example, according to research from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), the conditions of overweight and obesity run the United States an estimated $117 billion annually. According to researchers from the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH), obesity is related to 112,000 deaths annually in this country. It is surprising then, with the increased awareness and improved efforts at maintaining healthy diets and lifestyles in the United States by both individuals and medical professions, that most obese patients do not receive a diagnosis from their primary care physicians. This was the finding of a recent study done by researchers at the Mayo Clinic, Rochester, MN. 1 They used the Mayo Clinic primary care database to identify obese patients who had undergone general medical exams from November 1, 2004, to October 31, 2005, The comorbidities and illnesses associated with morbid obesity are numerous, and include type 2 diabetes, coronary heart disease, stroke, hypertension and almost all types of cancer. in a primary care clinic. Obese patients were considered to be those with a BMI of 30 or greater. In all, 9,827 patients were seen for a general medical exam. Of these, 2,543 were obese. Only 19.9% of these obese patients actually had a diagnosis of obesity documented, and only 22.6% had a documented obesity management plan. Staff physicians were also less likely than residents to document obesity as a diagnosis. “ M a k e a d i a g n o s i s o f obesity because making a diagnosis increases the chances that a management plan will be put into place,” said Warren Thompson, M.D. Clinicians have not traditionally tended to make a diagnosis of obesity in the past. The reasons are many, said Dr. Thompson, who is an associate professor of medicine at the Mayo Clinic. “It can be a difficult issue to discuss with patients. Patients do not like to be told that they are obese. There’s a bit of discomfort on the part of the patient as well as the clinician. Another problem is that obesity had not been regarded as a disease. Until 2004, Medicare did not cover obesity. This has contributed as well to the tendency for clinicians not to make this diagnosis,” explained Dr. Thompson. Clinicians must take a proactive role in the diagnosis and management of obesity, he continued. “I think that both clinicians and patients are well aware of the burden of obesity. What we’d like to stress to clinicians is that it’s important to make a diagnosis and discuss it with your patients. If you don’t discuss it, there’s no plan that will be formulated to deal with it.” Patients with a diagnosis of obesity were 2.5 times more likely to formulate a weight-loss management plan than those who had not been diagnosed. So simply being diagnosed as obese made it more likely that patients took the crucial step of improving their health by establishing a treatment plan with their physician. Dr. Thompson and his colleagues also found that older patients and men were significantly less likely to be diagnosed as obese, while those with a BMI of greater than 35, diabetes and obstructive sleep apnea were significantly more likely to be diagnosed. “In people with diabetes or obstructive apnea or those who are more obese (BMI over 35), physicians were more likely to make the diagnosis,” said Dr. Thompson. “So look out for cases where people are healthy, but just a little bit overweight but not significantly obese (BMI of 30-35). These are the people who are often missed. Those are the people we want to make sure the doctors reach,” he told M.D. News. “If someone walks into the office weighing 400 pounds, obviously, the physician and patient are considering obesity. But say, for instance, someone comes in weighing 220 pounds (this depends on their height, too). This person may well be obese, but neither the physician nor the patient may feel it’s a problem because the patient is healthy. These are the people we don’t want to miss because it is a problem for that patient, and losing weight will improve their health,” he stressed. THE BARIATRIC OPTION Currently, surgery for morbid obesity is considered by many to be the most effective treatment for obesity. Bariatric surgery has been proven to have significant benefits in obese individuals who have tried dieting, exercise and other options to lose weight, but have failed to do so. Research has shown that bariatric surgery is an effective long-term treatment of morbidly obese patients. Bariatric surgery includes laparoscopic and open gastric bypass surgery, laparoscopic adjustable gastric banding and duodenal switch. The number of bariatric surgeries performed in the morbidly obese population of the United States reached an estimated 205,000 surgeries in 2007, according to figures from GREATER AKRON/CANTON M.D. NEWS JANUARY-FEBRUARY 2008 | 17
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