Bariatric treatments for adult obesity - Institute of Health Economics

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Evidence from placebo-controlled clinical trials suggests that three anti-obesity drugs—orlistat,sibutramine, and rimonabant—are modestly effective in reducing weight and have different effectson cardiovascular risk. The SRs/HTAs assessed in this report did not include primary studies onhead-to-head comparisons of the three drugs; it is not clear at this time whether one particular drugis more efficacious than another.Although data from large, adequately powered, long-term RCTs are lacking, bariatric surgery appearsto be more effective than dietary therapy, with or without physical exercise, for the treatment ofsevere obesity in adults. Evidence from a small RCT also suggests that, compared to intensivemedical treatment, surgery results in significantly greater weight reduction in obese people (BMI 30to 40 kg/m 2 ) diagnosed with type 2 diabetes.Procedures that are mainly diversionary (for example, BPD) result in the greatest amounts of weightloss, hybrid procedures (for example, RYGB) are of intermediate effectiveness, and restrictiveprocedures (for example, AGB) result in the least amounts of weight loss. The choice betweenRYGB and AGB depends on trade-offs between the risk of adverse events and the need forprocedure conversion or reversals. The evidence base for sleeve gastrectomy was limited.Various patients’ characteristics and comorbidities play an important role, but these variables havenot been fully explored. The evidence base is biased and of poor quality due to short-term follow-upand high attrition rates. In addition, there is a lack of information as to how outcomes are measuredand analyzed.As obesity is a chronic disease and its etiology is complex, a comprehensive provincial weightmanagement program equipped with a multidisciplinary team, consisting of dieticians, physicaltherapists, psychologist, medical doctors/nurses, and bariatric surgeons, is necessary. Dietary therapyand physical exercise should be the cornerstone of such a program, upon which pharmacotherapyand bariatric surgery can be provided for appropriate individuals who are overweight or obese.Bariatric treatments for adult obesity 100
APPENDIX T.A: METHODOLOGYSearch strategyThe IHE Research Librarian conducted the literature search for publications published between2000 and April 8, 2010. The search was further limited to adult, human studies and to systematicreviews and Health Technology Assessment (HTAs). The search was developed and carried outprior to the study selection process.Search for systematic reviews/HTAs of RCTsA literature search was conducted using key health information resources including MEDLINE,EMBASE, the Cochrane Library, and the Centre for Reviews and Dissemination (CRD) databases,to identify systematic reviews/HTAs of RCTs published between 2000 and 8 April 2010. The searchwas limited to the last 10 years because of the ongoing evolvement of bariatric treatment strategies.Search for grey literatureGrey literature searches were conducted between 18 May 2010 and 4 June 2010 for informationabout local context and regulatory status (Health Canada). A thorough review of HTA agencywebsites was conducted, as were searches for clinical practice guidelines and ongoing clinical trials.Reference lists from the included studies were also checked for other relevant studies.Table T.A.1: Search strategyDatabaseThe Cochrane Database ofSystematic Reviewswww.thecochranelibrary.comMEDLINE (includes in processand other non-indexed citation)OVID Licensed ResourceEdition ordate searched Search Terms ††2000 – 2010 #1 (obes* OR superobes*):ti,ab,kw, from 2000 to 2010#2 (diet OR lifestyle OR "life style" OR exercise OR walking ORbehavioural OR behavioural OR cognitive OR psychological ORmodification):ti#3 "weight loss" OR "weight reduction" OR "weight management" OR"physical activity":ti,ab,kw#4 (sibutramine OR orlistat OR "appetite suppressants" OR "antiobesityagents" OR counseling OR "cognitive therapy" OR "behavioural therapy"OR psychotherapy OR counseling OR "patient education"):ti,ab,kw#5 (#1 AND ( #2 OR #3 OR #4 ))#6 (child not adult):ti#7 #5 not #635 reviews2000 –8 April 20101. *obesity/2. *obesity, morbid/3. or/1-24. (superobes* or obes* or bariatric* or weight).ti.5. 3 or 46. (unplanned weight or unintended weight or involuntary weight orantipsychotic or schizophreni* or bipolar or Parkinson* or Alzheimer* orsmoking or dementia or bulimi* or anorexi* or urinary incontinence or uior pelvic floor or asthma or adhd or attention-deficit or apnea or cancer orBariatric treatments for adult obesity 101
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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
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Overview of adult obesityOver the p
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the need for regular physical activ
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phenylpropanolamine/25. Sibutramine
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Complianceand AdherenceDemand andut
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Aetna Clinical PolicyBulletinswww.a
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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 112 and 113: group as compared to the VBG group.
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 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
Page 160 and 161: LSGmMAMDNAnssORQoLRCTRDRRRYGBSBPTGV
Page 162 and 163: Table T.F.1-2: Weight loss - Behavi
Page 164 and 165: Table T.F.1-4: Weight loss - Surger
Page 166 and 167: Table T.F.2: Quality of life (QoL)
Page 168 and 169: Curioni & Lourenco 2005 58Cholester
Page 170 and 171: Table T.F.3-3: Risk factors/comorbi
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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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