Bariatric treatments for adult obesity - Institute of Health Economics

The addition of a selected pharmacologic agent should be considered in adults with a BMI≥ 27 kg/m 2 and comorbidities or with a BMI ≥ 30 kg/m 2 who are not attaining or areunable to maintain clinically significant weight loss with lifestyle and behaviouralmodification interventions. Most guidelines recommend the use of orlistat or sibutramine asan adjunct therapy, which should be considered on an individual case-by-case basis followingassessment of risk and benefit.Bariatric surgery should be considered on an individual case basis, following assessment ofrisk/benefit in adults with clinically severe obesity (BMI ≥ 40 kg/m 2 or BMI ≥ 35 kg/m 2and severe comorbid disease), after appropriate non-surgical bariatric treatments have beentried and have failed to induce clinically significant weight loss. Identification of obesityrelatedcomorbidities that may improve after surgery should be considered. 2,6,13 According toNICE, in adults with a BMI > 50 kg/m 2 surgery can be offered as the first line option,without a trial of nonsurgical bariatric treatments. 13 Multi-disciplinary care is recommended to support surgical interventions. Patients shouldonly be referred to units that are:o able to assess patients prior to surgery;o able to offer a comprehensive approach to assessment, diagnosis, and treatment;o able and willing to provide care before, during, and after surgery;o able to provide long-term follow-up.These recommendations are based on data gathered from younger adult populations and there islimited evidence about their practical application in the elderly (those 65 years and older). 14,15,56,61,63,64-66,78,84-87For weight management in the elderly, it is recommended that the focus be shifted fromweight loss to maintenance of weight. The main goals are to improve physical function and QoL andto reduce dependency. The primary approach is lifestyle modification by using individualized andprudent dietary interventions and physical activity that minimizes muscle and bone loss andaccommodates concomitant chronic disease, sensory deficits, functional limitations, and livingenvironments, as well as strategies for overcoming the barriers to dietary change and physicalactivity. 61,63-65,85,86,143Pharmacotherapy for weight management is not usually indicated for the elderly with obesitybecause of the potential adverse effects and lack of experience in the use of bariatric medication inthis population. 61,63-65,84,87 The use of bariatric surgery for weight management in the elderly remainscontroversial due to concerns about their greater risk for perioperative morbidity andmortality. 14,15,56,61,63-65,78,120 However, bariatric surgery may be considered for obese elderly persons(those 60 years and older) who have functional impairments and/or metabolic complications thatare expected to benefit from weight loss and to improve QoL. 46,56,78,120All reviewed CPGs recommend an individualized, client-centred, comprehensive weightmanagement program to achieve realistic weight loss and weight maintenance goals. 1,2,6,7,13,27,108 Theyall acknowledge that bariatric treatments require significant lifestyle and behavioural changes andemphasize the role of working together during bariatric therapy to create a nonjudgmentalatmosphere and the need for supportive communication in medical encounters. They alsoemphasize that the decision to attempt bariatric treatment should take into account the obeseindividual's readiness to make the necessary changes.Bariatric treatments for adult obesity 28