Bariatric treatments for adult obesity - Institute of Health Economics

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group as compared to the VBG group. The other trial did not find any significant differencebetween mini-gastric bypass patients and RYGB patients. Two trials used another obesity-specificmeasure—the Moorehead-Ardelt instrument—but none of the five domains showed significantresults.Of the three reviews on dietary therapy/physical exercise, while two reviews 56,58 did not look atHrQoL outcome, the third review 57 did not identify any data on HrQoL among included trials. Thereview 15 on behavioural therapy did not find any data on HrQoL. The three reviews 20,59,60 ofantiobesity medications did not examine the effects of drugs on HrQoL.MortalityNo data were available on the effect of anti-obesity drugs on mortality or cardiovascular morbidity.The CADTH report 38 assessed overall mortality following bariatric surgeries. In the comparison ofone surgery with another surgery or standard care (diet and exercise), an analysis of 23 RCTs withfollow-up of less than five years found no significant difference in mortality risk (30-day mortality,or mortality during follow-up) between any pair of interventions.An analysis of seven RCTs with 574 patients showed that the risk difference of death betweenlaparoscopic and open surgeries was not significant.Long-term outcomesOne systematic review 67 specifically examined the effect of bariatric treatment strategies on longtermoverall mortality. Eight prospective studies with a follow-up period of 5 years or longer wereincluded in this review (see Table T. F.4). This review assessed the effects of both intentional andunintentional weight loss, but did not clearly and consistently describe bariatric interventions used inthe eight primary studies.Results for women onlyTwo studies reported the mortality risk with weight loss for white women in the United States. Onestudy showed significantly increased mortality for all overweight or obese women with weight loss.However, because the reference group was those of normal weight with small weight loss, the twogroups were not comparable. The other study involved women who were at least overweight(BMI > 25 kg/m 2 ). Information about weight loss intention and obesity-related diseases wasobtained from each person. The study showed that, for those with obesity-related diseases and theintention to lose weight, the mortality risk significantly improved in women who lost 20 pounds ormore within 1 year, compared to those without weight change. However, for those who lost lessthan 20 pounds and who took more time (1 year or longer) to lose the weight, no significantdifference in mortality risk was found between the weight loss group and the group having noweight change.Results for men onlyThree studies examined the long-term effect of weight loss in men. One study included men whowere at least overweight (BMI > 25 kg/m 2 ). The intention of weight loss and the presence ofcomorbidities were considered separately. Compared to the weight-stable group, intentional weightloss of 20 pounds or more for longer than 1 year was detrimental for all men. Unintentional weightloss was also marginally detrimental. However, intentional weight loss of less than 20 pounds in menwith comorbidities did not show any detrimental effects.Bariatric treatments for adult obesity 88
Another study also reported that, when compared to the weight-stable group, weight loss wasdetrimental for non-cancer mortality. However, the intentionality of weight loss was not reported.The third study conducted an analysis on overweight men and adjusted for several variables tocontrol for demographic variations and the probably of underlying diseases. This study showed thatmortality risk improved in the intentional weight loss group as compared to the weight-stablesubgroup; however there was no difference for those with comorbidities or who lost weightunintentionally.Overall, the impact of weight loss on mortality in men is not clear. A meta-analysis of all the studiesusing a random effect model demonstrated that, as compared to the reference group of overweightbut weight-stable men, the overall effective weight loss was shown to be slightly detrimental. Whenstudies with the outcome of intentional weight loss were combined using a fixed effect model, thehazard ratio became non-significant.Results for women and men combinedThree studies—one conducted in the United States, one in Canada, and one in Finland—examinedthe impact of weight loss on mortality risk in overweight or obese men and women. All three studiesreported mortality for a similar time period, from the mid 1980s to the beginning of the newmillennium. The participants in the US study were about a decade older than those in the otherstudies, hence the average age varied slightly between the studies.The US study adjusted their analysis for more than 13 variables and also attempted to account forknown underlying diseases. For those who claimed to be trying to lose weight, the effects weremarginally beneficial if they remained weight-stable or lost small amounts of weight. In contrast, theFinnish study found that for those with intentional weight loss, the effect of weight loss wasdetrimental. A meta-analysis of these two studies indicated no significant difference between thegroups.The Canadian study examined the impact of bariatric surgery on mortality in morbidly obesepatients. Of the 1035 patients who received surgery, seven patients (0.7%) died as compared tothose under standard treatment, where 354 of 5746 patients (6.2%) died. Usually surgery is onlyconsidered for those to whom obesity is life-threatening. Consequently, the surgical group does havea substantially reduced mortality risk as compared to a comparable control group who did notundergo surgery. Similarly, the effects of the surgery are difficult to disentangle from any weight lossbenefits for this subgroup.Factors that may have an impact on the outcomesGender differences, the presence of comorbidities, and the notion of intentionality of weight losshave been identified as important factors that may have impacted outcomes. With respect to gender,for studies with men only and with men and women combined, the effects of weight loss onmortality were inconsistent regardless of intentionality. On the other hand, one study demonstratedbenefits from weight loss in overweight or obese women with pre-existing comorbidities. However,patients with diabetes, regardless of gender, benefited from intentional weight loss.Methodological limitationsBenefits of weight loss on all-cause mortality for overweight or obese patients are meager. The mostimportant explanations are intentionality, self-reporting of weight loss, and the time lapse betweenthe last recorded weight loss measurement and the mortality outcome.Bariatric treatments for adult obesity 89
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Alberta STE ReportBariatric treatme
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Alberta STE ReportBariatric treatme
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EXECUTIVE SUMMARYSocial and System
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Three surgical procedures—adjusta
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Costs of Bariatric Surgery and Pote
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Regulatory status .................
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TABLES AND FIGURESSection One: Soci
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ABBREVIATIONSAll abbreviations that
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LYMmMAMDMUHCNANHLBINHSNICENIHNNHNPH
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Bariatric physician: a licensed Doc
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High-density lipoprotein (HDL): a f
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Very-low-calorie diet (VLCD): a die
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Additional Internet searches were c
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This report addresses obesity in ad
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Many systemic factors have been ide
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Severe obesity is associated with d
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eport their height and under-report
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Also using self-reported data from
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An examination of overall obesity d
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Table S.2 presents the associationa
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• have multiple focal points and
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The main problem in any weight mana
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food, and a negative body image. As
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directly causes death. 61 To the ex
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The addition of a selected pharmaco
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lack of formal training in nutritio
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slightly more likely to have prescr
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selection criteria, have facilities
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Barriers to using appropriate baria
Page 62 and 63: Overview of adult obesityOver the p
Page 64 and 65: the need for regular physical activ
Page 66 and 67: phenylpropanolamine/25. Sibutramine
Page 68 and 69: Complianceand AdherenceDemand andut
Page 70 and 71: Aetna Clinical PolicyBulletinswww.a
Page 72 and 73: Overweight 123,821 172,971 157,623
Page 74 and 75: REFERENCES1. 2006 Canadian clinical
Page 76 and 77: 34. Gostin LO. Fast and supersized:
Page 78 and 79: 69. Klarenbach S, Padwal R, Wiebe N
Page 80 and 81: 105. Hill JO, Thompson H, Wyatt H.
Page 82 and 83: 141. Ross R, Bradshaw AJ. The futur
Page 84 and 85: 172. Arkinson J, Ji H, Fallah S, Pe
Page 86 and 87: This section will address a set of
Page 88 and 89: dietary therapy is to reduce total
Page 90 and 91: Additional benefits of exercise ove
Page 92 and 93: medications that inhibit intestinal
Page 94 and 95: Rimonabant may be considered for pa
Page 96 and 97: Long-term complications are specifi
Page 98 and 99: Devices used for bariatric surgeryH
Page 100 and 101: Description of the Included Systema
Page 102 and 103: AEs for sibutramineAs compared to a
Page 104 and 105: Evidence on Efficacy/EffectivenessW
Page 106 and 107: Table T.7: Effects of behavioural t
Page 108 and 109: SurgeryDescription of the included
Page 110 and 111: follow-up time was 3 years. Results
Page 114 and 115: The authors identified many methodo
Page 116 and 117: The investigators pointed out that
Page 118 and 119: approximately 3 to 5 kilograms. For
Page 120 and 121: for studies with a mean age of part
Page 122 and 123: Examining whether use of any of the
Page 124 and 125: Evidence from placebo-controlled cl
Page 126 and 127: colorectal or gastroesophageal or f
Page 128 and 129: Web of ScienceISI Interface License
Page 130 and 131: AMA Clinical PracticeGuidelineswww.
Page 132 and 133: critical appraisal of the included
Page 134 and 135: APPENDIX T.B: EXCLUDED STUDIESTable
Page 136 and 137: Padwal R, Li SK, Lau DC. Long-term
Page 138 and 139: Quality subsection 1: At least MEDL
Page 140 and 141: Quality subsection 5a:Study quality
Page 142 and 143: Partially reported: The study types
Page 144 and 145: Table T.C.1: Results of quality ass
Page 146 and 147: Table T.C.1: Results of quality ass
Page 148 and 149: APPENDIX T.D: CHARACTERISTICS OF SY
Page 150 and 151: Table T.D.1: Characteristics of the
Page 156 and 157: APPENDIX T.E: EVIDENCE TABLE ON SAF
Page 158 and 159: Serious surgical complicationsSurgi
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Table T.F.1-2: Weight loss - Behavi
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Table T.F.1-4: Weight loss - Surger
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Table T.F.2: Quality of life (QoL)
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Curioni & Lourenco 2005 58Cholester
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Table T.F.3-3: Risk factors/comorbi
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Table T.F.3-5: Long-term effects of
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Maciejewski et al., 2005 65Avenell
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Table T.G.2: Effects of bariatric s
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Table T.G.4: Effects of bariatric s
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18. Cerulli J, Lomaestro BM, Malone
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50. Health Canada Drug Product Data
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SECTION THREE: ECONOMIC EVALUATIONC
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Definition of bariatric surgical pa
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etween surgical interventions, the
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concluded that adding orlistat to L
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Weight management program (WMP) ver
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groups. Compared with standard care
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Results from Analysis of Provincial
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DiscussionThe objectives of the eco
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surgical suites, and so on. The bud
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APPENDIX E.A: LITERATURE SEARCH SUM
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CRD Databases(DARE, HTA & NHS EED)h
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Web of ScienceISI Interface License
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NEOS Librarywww.library.ualberta.ca
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Table E.A.2: Evidence table of revi
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ResultHealth outcomesCostsMarginal
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CostsMarginal analysisThe cost anal
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Time Horizon/discount rateCurrency/
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Objectivestudy perspective: society
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S4Economic burden of obesityMean co
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15. Lacey LA, Wolf A, O'shea D, Ern
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Author Contribution StatementsPaula
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