Bariatric treatments for adult obesity - Institute of Health Economics

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AcknowledgementsThe Institute of Health Economics is grateful for the provision of information by, and forcomments from, the Expert Advisory Committee.We wish to thank Maria Ospina for her assistance with quality assessment of studies included in thetechnical section of this report.The views expressed in the final report are those of the Institute of Health Economics.The authors would like to thank Wendy McIndoo (IHE) for her support with checking referencesand formatting/editing the document and Ms. Liz Dennett, Information Specialist, Institute ofHealth Economics, Edmonton, Alberta for searching the literature and information support.Corresponding AuthorPlease direct any inquiries about this report to Christa Harstall, charstall@ihe.caFundingThis report was supported by a financial contribution from Alberta Health and Wellness (AHW)through the Alberta Health Technologies Decision Process: the Alberta model for health technologyassessment and policy analysis. The completed report was submitted to AHW in March 2011.The views expressed herein do not necessarily represent the official policy of Alberta Health andWellness.Declared Competing Interest of AuthorsNoneSuggested Citation (ICJME or Vancouver Style)Institute of Health Economics. Bariatric treatments for adult obesity. Edmonton AB: Institute of HealthEconomics. 2012.Web AddressThis publication is available for free download from the IHE website at: http://www.ihe.ca.Reproduction, redistribution, or modification of the information for any purposes is prohibited without the expresswritten permission of the Institute of Health EconomicsInstitute of Health Economics, 2011www.ihe.caBariatric treatments for adult obesity – March 2012i
EXECUTIVE SUMMARYSocial and System DemographicsAdult obesity has emerged as a chronic medical condition characterized by an accumulation ofexcess body fat caused by a long-term energy imbalance that mainly results from complexinteractions of biological, environmental, and behavioural factors. In practice, it is defined accordingto body mass index (BMI), categorized as follows:BMI Range Type of Obesity Obesity Class30 kg/m 2 to 34.9 kg/m 2 mild obesity Class I obesity35 kg/m 2 to 39.9 kg/m 2 moderate obesity Class II obesity40 kg/m 2 or greater severe/extreme/morbid obesity Class III obesityAdult obesity is associated with multiple organ-specific and psychosocial consequences that mayresult in reduced quality of life and increased morbidity and premature mortality. The most seriousadverse health risks and consequences are associated with severe (class III) obesity.In Canada, as in other countries, the prevalence of obesity during the past 30 years has increasedprogressively within all demographic groups and continues to rise. This increase is influenced bynumerous individual-level and environmental factors.Among Alberta’s 2007 population of adults (aged 18 years and over), 17.7% were classified as obese,with 12.5% in class I, 3.7% in class II, and 1.5% in class III. These rates were based on self-reporteddata from the 2007 Canadian Community Health Survey (CCHS). They are considerably lower thanthe latest available directly measured rates from the 2004 CCHS data, where the measured adultobesity rate was 25.2% and the rates for classes I, II, and III obesity were 15.4%, 6.7%, and 3.2%,respectively.According to evidence-based recommendations, when addressing adult obesity, both preventionstrategies (to keep more individuals from becoming obese) and bariatric therapy (to assist thosediagnosed with obesity in managing their weight problems) should be considered. A comprehensiveand multisectoral approach to adult obesity prevention is recommended. Lifestyle and behaviouralmodification, based on intensive patient education and counseling, is recommended as an essentialpart of effective adult obesity management. Pharmacotherapy may be added if lifestyle andbehavioural modification interventions alone are insufficient. For severe and moderate obesity (BMI≥ 40 kg/m 2 and BMI ≥ 35 kg/m 2 with comorbidities) refractory to appropriate non-surgicaltreatments, bariatric surgery may be an appropriate option when combined with long-term lifestylemodifications.Bariatric treatment options should be stratified according to BMI and waist circumferencemeasurements, the presence of associated health risks and consequences, readiness for change andwillingness to comply with an individualized treatment plan, and failure of previous bariatrictreatments. Key components of quality bariatric care include:appropriate selection of patients for each treatment strategy;the availability of a multidisciplinary team that includes dedicated and appropriately trainedand credentialed personnel;Bariatric treatments for adult obesity – March 2012ii
Page 1 and 2: Alberta STE ReportBariatric treatme
Page 3: Alberta STE ReportBariatric treatme
Page 7 and 8: Three surgical procedures—adjusta
Page 9: Costs of Bariatric Surgery and Pote
Page 12 and 13: Regulatory status .................
Page 14 and 15: TABLES AND FIGURESSection One: Soci
Page 16 and 17: ABBREVIATIONSAll abbreviations that
Page 18 and 19: LYMmMAMDMUHCNANHLBINHSNICENIHNNHNPH
Page 20 and 21: Bariatric physician: a licensed Doc
Page 22 and 23: High-density lipoprotein (HDL): a f
Page 24 and 25: Very-low-calorie diet (VLCD): a die
Page 26 and 27: Additional Internet searches were c
Page 28 and 29: This report addresses obesity in ad
Page 30 and 31: Many systemic factors have been ide
Page 32 and 33: Severe obesity is associated with d
Page 34 and 35: eport their height and under-report
Page 36 and 37: Also using self-reported data from
Page 38 and 39: An examination of overall obesity d
Page 40 and 41: Table S.2 presents the associationa
Page 42 and 43: • have multiple focal points and
Page 45 and 46: The main problem in any weight mana
Page 47: food, and a negative body image. As
Page 50 and 51: directly causes death. 61 To the ex
Page 52 and 53: 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
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REFERENCES1. 2006 Canadian clinical
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34. Gostin LO. Fast and supersized:
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69. Klarenbach S, Padwal R, Wiebe N
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105. Hill JO, Thompson H, Wyatt H.
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141. Ross R, Bradshaw AJ. The futur
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172. Arkinson J, Ji H, Fallah S, Pe
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This section will address a set of
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dietary therapy is to reduce total
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Additional benefits of exercise ove
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medications that inhibit intestinal
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Rimonabant may be considered for pa
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Long-term complications are specifi
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Devices used for bariatric surgeryH
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Description of the Included Systema
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AEs for sibutramineAs compared to a
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Evidence on Efficacy/EffectivenessW
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Table T.7: Effects of behavioural t
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SurgeryDescription of the included
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follow-up time was 3 years. Results
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group as compared to the VBG group.
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The authors identified many methodo
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The investigators pointed out that
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approximately 3 to 5 kilograms. For
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for studies with a mean age of part
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Examining whether use of any of the
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Evidence from placebo-controlled cl
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colorectal or gastroesophageal or f
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Web of ScienceISI Interface License
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AMA Clinical PracticeGuidelineswww.
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critical appraisal of the included
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APPENDIX T.B: EXCLUDED STUDIESTable
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Padwal R, Li SK, Lau DC. Long-term
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Quality subsection 1: At least MEDL
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Quality subsection 5a:Study quality
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Partially reported: The study types
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Table T.C.1: Results of quality ass
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Table T.C.1: Results of quality ass
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APPENDIX T.D: CHARACTERISTICS OF SY
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Table T.D.1: Characteristics of the
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APPENDIX T.E: EVIDENCE TABLE ON SAF
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Serious surgical complicationsSurgi
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LSGmMAMDNAnssORQoLRCTRDRRRYGBSBPTGV
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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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