Bariatric treatments for adult obesity - Institute of Health Economics

necessary for weight loss maintenance depends not on complying with demands for change butrather on accepting personal ownership of the regulation for change. 91Areas of uncertaintyThere is still uncertainty regarding the proper roles of non-surgical and surgical treatment for obesityand regarding what constitutes success for medical bariatric interventions. 5,14,19,31,36,60,83,107,114,115,137-142This clinical confusion reflects a knowledge gap and is also related to the absence of a triage strategyfor patients with obesity. 14 In part, this also reflects the varying patient and clinician perceptionsabout obesity and the effectiveness and safety of bariatric treatments, and reflects a debate about thecause of obesity and, by extension, the appropriate bariatric treatment.Varied opinions regarding weight management approaches parallel differing philosophies regardingthe obesity problem. These include approaches focusing on:weight loss outcomes;healthful lifestyle approaches directed toward changing eating behaviours and physicalactivity patterns with or without weight loss;non-dieting and size acceptance approaches where treatment goals include improved selfesteem,fat acceptance, and/or advocacy for decreased weight discrimination.This context of divergent philosophies has likely created confusion and diversity of practice amonghealthcare providers.The obesity classification based on anthropometric measurements and the observed presence ofuncomplicated obesity may be part of the barrier for considering patients for various bariatrictreatments. 5,14,26,36,51,60 It has been stated that the eligibility criteria based on anthropometricmeasurements alone might have created a subset of patients who “meet the numbers” but not theclinical threshold for referral. 14 There appears to be a population of individuals classified as obesewho do not present with obesity-associated health risks and adverse consequences (the so-called“healthy fat,” or metabolically normal). 14,36 Healthcare providers cannot determine which individualswith obesity are at highest risk for functional, social, QoL, and clinical decline, or for prematuredeath without significant weight loss. 14 Sharma and Kushner 5 recently proposed that the currentanthropometric definitions of obesity be complemented by a clinical staging system aimed toprovide a meaningful framework for medical decision-making, clinical research, and reimbursementpolicies.The sources of variability in response to bariatric treatments also remain unclear, because there is noadequate explanation of why some people adopt the attitudes and behaviours needed for long-termweight management while others do not. 14,26,36,46,51,58,77,114,115 Obesity is a heterogeneous condition and,in real life settings for weight management programs, physiological and psychosocial individualfactors (some of which may carry genetic influence) interact with environmental factors in acomplex manner, producing a wide range of individual responses. 14,58,77,115 Concern has been raisedthat the psychological, biological, and environmental differences among individuals with obesity aretoo large for any single obesity treatment to ever be effective in terms of long-term weight control.Any treatment will be useful to some obese persons, but no single treatment will be effective for all,suggesting the need for better matching treatment features with patients’ characteristics and needs.The link between obesity and premature mortality has been debated and it appears that theresolution of this matter cannot be resolved with current data. 1,14,36,59 Obesity very rarely, if ever,Bariatric treatments for adult obesity 25