Bariatric treatments for adult obesity - Institute of Health Economics

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This section will address a set of more detailed questions from Alberta Health and Wellness in termsof condition, pattern of care, effects and effectiveness, and program context.ConditionWhat is the aetiology of the condition that the bariatric treatment strategies are meant toaddress?What are clinical indicators for the various bariatric treatment strategies for obesity?What is the best practice for treating obesity? Which technologies have received Health Canada approvals for the treatment of obesity, andfor which condition(s) they have been approved?Pattern of careWhat is the history behind the development of the various bariatric treatment strategies?What are the current options and what is the standard/gold standard procedure?What are the current situations and trends of use of bariatric treatment strategies for obesity? Does the potential exist for one bariatric treatment strategy to replace another in thetreatment of obesity?Effects and EffectivenessWhat are the actions or effects of the bariatric treatment strategies?What are the differences between the strategies across sub-populations (defined according toBMI)?What are the expected benefits of various strategies across sub-populations (definedaccording to BMI)?What are the risks, side effects, and safety issues for patients and providers for variousstrategies across sub-populations (defined according to BMI)?What are the measurements and indicators of outcomes (benefits, risks, side effects)?What is the available evidence of benefit or effectiveness with respect to key outcomes? Are the outcomes dependent on the following factors?o patient characteristics (such as age, gender, comorbidity, co-medication, etc.)o specific training or experience of the providers (learning curve)o equipment usedo other factorsProgram ContextAre any other interventions/technologies required for appropriate use of bariatric treatmentstrategies?Can any of the bariatric treatment strategies use equipment already being used for publiclyfunded procedures?Bariatric treatments for adult obesity 62
Are any follow-up or related procedures required?Project scopeThe scope of the T section of the report was defined as follows:Population: adult patients ( 18 years) who are overweight (defined as BMI between 25 and 29.9kg/m 2 ) or obese (defined as BMI ≥ 30 kg/m 2 ).Intervention: any kind of bariatric treatment strategies (dietary therapy, physical exercise,behavioural therapy, pharmacotherapy, and surgeries) or any combination of different treatmentstrategies.Comparator: comparisons between and within treatment strategies.Outcome measures: safety outcomes include adverse events/complications associated withtreatment strategies; efficacy/effectiveness outcomes include any of the following: weight change,health-related quality of life, prevention/improvement in risk factors and comorbidities,psychological measurement, and mortality.Description of TechnologyOverview of bariatric treatment strategiesThe prevalence of obesity continues to increase worldwide. The cause of obesity is complex andmulti-factorial. 1 Major genetic, environmental, and socio-cultural (or behavioural) factors haveplayed important roles in the development of obesity. In particular, alterations of an individual’senergy balance caused by inappropriate food intake and/or reduction in physical activity levels havecontributed significantly to the current worldwide epidemic of obesity. 2Population approaches to dealing with the obesity problem have focused on reducing fat intake inassociation with increased physical activity. Diet and lifestyle changes have been the cornerstones forobesity treatment over the years.People lose weight when energy expenditure exceeds energy intake for a defined period of time. 3Successful maintenance of weight loss occurs when expenditure and intake are matched at thereduced body weight for a continued period of time. 3Currently available strategies for treating overweight and obesity include: 1,4dietary therapyphysical exercisebehavioural therapypharmacotherapy surgeryDietary therapyDefinitionReduction of body weight requires a deficit in caloric intake. A key element of weight management isa moderate reduction in caloric intake to achieve a slow but progressive weight loss. 5 The goal ofBariatric treatments for adult obesity 63
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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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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
Page 54 and 55: lack of formal training in nutritio
Page 56 and 57: slightly more likely to have prescr
Page 58 and 59: selection criteria, have facilities
Page 60 and 61: 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 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.
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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
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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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Bariatric treatments for adult obesity - Institute of Health Economics

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