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Bariatric Surgery vs. weight management

Surgery remains the most effective and cost-effective long-term approach to reducing weight for adults adults with severe obesity, according to research from the University of Aberdeen, Aberdeen, UK Health Forum, London and the University of Oxford, Oxford, UK. However, the study also found that high quality weight management programmes (WMPs) are effective tools in reducing weight for up to 10 years in some cases.

"The purpose of this study was to examine the available evidence looking at the effectiveness and cost-effectiveness of different weight management procedures from the perspective of the NHS,” said lead author, Professor Alison Avenell from the University of Aberdeen. "Whilst the study shows that surgical interventions remain much more effective, provision of surgery for obesity management by the NHS is presently very low. Other weight management programmes can be effective in terms of helping people who are severely obese lose weight and are cost-effective for the NHS."

The outcomes of the REBALANCE study, were published in the paper, ‘Bariatric surgery, lifestyle interventions and orlistat for severe obesity: the REBALANCE mixed-methods systematic review and economic evaluation’, which was funded by the National Institute for Health Research (NIHR). In the study, the researchers reviewed 236 studies looking at evidence for acceptability, effectiveness and value for money of surgery, diet and exercise weight management programmes, and the drug orlistat.

They undertook four systematic reviews, which were of:

  • Randomised controlled trials (RCTs) or quasi-randomised trials of bariatric surgery, lifestyle WMPs and orlistat (approved by the National Institute for Health and Care Excellence) with mean or median follow-up durations of ≥ 12 months. We included comparisons between interventions or comparisons with usual care/controls.
  • UK lifestyle WMPs and orlistat with any study design and a mean or median follow-up duration of ≥ 12 months.
  • Qualitative and mixed-methods research on the feasibility and acceptability of lifestyle WMPs and orlistat (including views of professionals involved in care).
  • Economic evaluations (trial analyses and decision modelling studies) of bariatric surgery, lifestyle WMPs and orlistat.
  • Data from the systematic review of RCTs populated a microsimulation model predicting costs, outcomes and cost-effectiveness of the most-effective programmes over a 30-year time horizon from a NHS perspective for a population representative of all adults with a BMI of ≥ 35 kg/m2. The UK Health Forum microsimulation model assessed the cost-effectiveness of:
  • the Look AHEAD trial WMP versus baseline UK general population BMI trends
  • a very low-calorie diet (VLCD) added to a WMP versus a WMP alone, with both versus the baseline UK general population BMI trend
  • Roux-en-Y gastric bypass (RYGB) versus a WMP, with both versus the baseline UK general population BMI trends.

The outcomes were weight change (primary outcome), cardiovascular risk factors, psychological well-being, adverse events, quality of life, process outcomes, qualitative outcomes, costs and economic evaluations.

Outcomes

The reported that bariatric surgery, especially RYGB, produced greater long-term weight change than any of the WMPs [RYGB mean –20.23kg, 95% confidence interval (CI) –23.75 to –16.71kg] at 60 months. Adding a VLCD to an existing WMP gave an additional mean weight change of –4.41kg (95% CI –5.93 to –2.88 kg) at 12 months. Orlistat and dietary counselling reduced weight regain after VLCDs. Long-term weight maintenance after weight-loss programmes that did not incorporate VLCDs was improved by orlistat and follow-up in person or by telephone.

Data analyses initially favoured low-carbohydrate (< 40 g/day) reducing diets compared with low-fat reducing diets (mean weight change of –1.16 kg, 95% CI –2.13 to –0.19kg), and higher protein (≥ 30% energy) reducing diets compared with lower protein reducing diets (mean weight change of –0.91 kg, 95% CI –1.83 to 0.00kg) at 12 months, but not beyond 12 months. The use of meal replacements, such as giving component parts of VLCDs, was associated with greater weight loss, but only at 12 months (mean weight change of –2.75kg, 95% CI –4.01 to –1.48kg).

More intensive interventions, with more contacts with WMP personnel (in person or remotely), were usually associated with greater weight loss and better weight maintenance. Initial inpatient programmes were not associated with greater weight loss. Interventions delivered to groups rather than to individuals had greater weight loss results, but groups usually had more contacts. There was little evidence that incorporating family members for support and modifying the home environment were beneficial. Similarly, interventions that were weight neutral or did not target weight loss were less effective than those with a prescribed calorie content or deficit.

In summary, they reported that:

  • Bariatric surgery had the best long-term weight-loss results and could be a good use of NHS resources, compared with no surgery or weight management programmes on their own.
  • Of non-surgical approaches, very low-calorie diets produced the best weight-loss result at 12 months, but it was unclear if weight-loss was any greater than standard WMPs for longer than this.
  • Adding a very low-calorie diet to an existing weight management programme was shown to not be a good use of NHS resources. However, most weight management programmes, including those with very low-calorie diets, appeared to be a good use of NHS resources compared with doing nothing at all.
  • Low-carbohydrate Atkins-type diets, higher protein intakes or the use of meal replacements had small added effects on improving weight loss compared to other WMPs at 12 months. They also found no evidence that they were better than other diets after 12 months.
  • The best result for long-term non-surgical weight loss (over nearly 10 years) came from an intensive WMP with all of the following: a low-fat reducing diet, a calorie goal of 1200–1800 kcal/day, initial meal replacements or meal plans, a tailored exercise programme, cognitive behavioural therapy, intensive group and individual support, and follow-up by telephone or e-mail. However, this type of WMP would be more costly for the NHS than simpler WMPs.
  • Other components of effective interventions included increasing physical activity to help prevent long-term weight regain and receiving longer-term help with diets or using the drug orlistat. Adding telephone or internet support, and group support, also helped to keep weight off.
  • Participants in weight management programmes valued novelty, weight management programmes endorsed by health-care providers and belonging to a group of people who shared similar issues.

In addition, they noted that weight-management programmes were generally cost-effective compared with a baseline of current UK general population obesity trends [incremental cost-effectiveness ratio < £20,000/quality-adjusted life-year (QALY)]. However, the addition of a VLCD to a WMP was not cost-effective. The Look AHEAD programme was borderline cost-effective compared with current population obesity trends, with an improved case for cost-effectiveness under longer-term weight regain assumptions.

RYGB was the most cost-effective strategy overall in the base-case analysis, over a 30-year time horizon, although the model did not replicate long-term cost savings for surgery suggested by some studies in systematic review. The economic model results were sensitive to assumptions about weight regain, model time horizon and discount rates for costs and QALYs.



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Increasing access to surgery and preventing post-op weight regain

There is growing evidence that there is not one mechanism for bariatric surgery’s effects but many
Surgery’s effects are not just hormonal, not just restrictive and not just a change is the patient’s dietary habits and lifestyle – it is a combination of all three
 
Tuesday, November 20, 2018 - 07:53

Owen Haskins - Editor in chief, Bariatric News

In a wide-ranging interview, Bariatric News talked to Mr Shaw Somers, upper gastrointestinal and bariatric (metabolic) Consultant Surgeon with Streamline Surgical and President of the British Obesity & Metabolic Surgery Society (BOMSS), about the lack of access to surgery, the need to educate people on the causes of obesity and how to treat post-operative weight regain.

 

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Shaw Somers

“The problem we face in the UK is of a publicly-funded health system in which the government absolutely dictate what and who we can and can’t operate on, based on money,” Mr Somers began. “Unfortunately, we still have a disconnect in the UK between what the National Institute for Health and Care Excellence (NICE) guidance states and what politicians and the people within NHS England are prepared to accept as standards of care. We have NICE guidance which is very clear on how and what we should be spending money on in terms of treating obesity and yet it seems to be completely voluntary for commissioners to opt out of if they want. We now have less Tier 4 commissioned surgery than we did three years ago and only 44% of all commissioning groups procure bariatric services.”

He believes the lack of awareness about the causes of obesity and how to treat obesity comes down to a lack of education, as many people do not understand that obesity is a disease, and stated that it is up to obesity specialists including bariatric surgeons, researchers, nurses, dieticians etc to educate colleagues, politicians, policy-makers, commissioning groups, the media and the public that obesity is an illness - rather than a lifestyle choice.

Obesity is not a lifestyle choice

“I have met thousands of people with obesity and not one of them choose to be obese. Our great challenge will be to convince people that obesity is a disease and that there are treatments available that work,” said Mr Somers. “To ask people to eat less and exercise more is a ridiculous over simplification of the scientific evidence and is ignoring the fact that much of your weight is determined by genetics. I think we need to start exposing fat shaming for what it is - and that is the prejudice of ignorance - it does not work to help people lose weight, in fact it is counterproductive.”

He emphasised that BOMSS is still very busy behind the scenes lobbying the various stake-holders to raise awareness and try and improve access to all treatments for obesity, and will continue to work hard on behalf of the bariatric community to educate and demonstrate that bariatric procedures are safe, effective and have not only resulted in reducing the weight of tens of thousands of people over the years but have also improved their overall health and quality of life by reducing their co-morbidities, and improving quality of life.

"There is also evidence that shows sleeve and bypass procedure tend to fade with time, this ‘fatigue’ or loss of restriction means the restrictive and hormonal effects of the procedure diminish over time.”

He explained that people need to understand the nature of obesity as an illness and that obesity is about how our brain perceives food and satisfaction, and when that relationship becomes disordered, we start to eat more. Mr Somers added that is not because we are inherently greedy but because our brain does not respond in the way it should to food. The reason for this are multifactorial including the type of food we eat, the stresses of modern day life, mental illness - including anxiety and depression – all change the way the brain functions, and this includes the way the brain responds to food.

Bariatric and metabolic surgery

He explained that there is growing evidence that there is not one mechanism for bariatric surgery’s effects but many. He said that surgery’s effects are not just hormonal, not just restrictive and not just a change is the patient’s dietary habits and lifestyle – it is a combination of all three. He believes that there are three phrases to bariatric surgery’s effects:
1) There is an initial ‘shock and awe’ phase that changes a patient’s experience when the eat after the procedure, which includes a feeling of restriction.
2) A phase of hormonal effects where the actual physiology of the bariatric procedure changes how the patient feels and how they work with food, and;
3) The longer-term dietary rehabilitation and the longer-term effects of surgery that either help the patients maintain their habits or not - and it is here where weight regain occurs.

There are now many tens of thousands of people in the UK that have had successful bariatric procedures, unfortunately the human body adapts and changes over time, and these changes bring with it the possibility of weight regain.

According to Mr Somers, the first two phases work because of the restrictive effects of the procedure, depending on the procedure. If either the physical or hormonal effects are no longer present, this is when weight regain occurs. The question then becomes: How do you maintain the effects of the operation in the long-term? One solution is to maintain restriction.

“We know from long-term gastric band data that if the band is still in place and there have not been any complications then the outcomes are good, and there are several long-term gastric band studies that are at least as good as the long-term sleeve and bypass data. We know that once band patients are stable they don’t regain weight because the band is still working and is having an effect. There is also evidence that shows sleeve and bypass procedure tend to fade with time, this ‘fatigue’ or loss of restriction means the restrictive and hormonal effects of the procedure diminish over time.”

The ‘banded procedure’

One possible way to prevent ‘surgical fatigue’ and maintain restriction is to perform a ‘banded bypass’ or ‘banded sleeve’, in which a surgeon places a band or a MiniMizer Ring (Bariatric Solutions) around the gastric pouch to prevent pouch dilatation.

According to Mr Somers, patients who have a MiniMizer Ring find that the ‘fatigue’ effect does not occur as they still have an element of restriction and that stops weight regain in the long-term. Whilst the initial phases weight loss for ‘banded’ patients is generally the same as non-banded patients, it is the prevention of long-term weight regain that is the real benefit of using a device such as the MiniMizer Ring.

Mr Somers has been using the MiniMizer Ring for about three years and has performed about 40 - all private cases - as the MiniMizer Ring is not freely available on the NHS.

“I routinely offer the MiniMizer Ring to patients if they are undergoing a revision procedure from a band to a bypass, as the one thing they complain about is a loss of restriction and they don’t feel comfortable working with no restriction element,” he explained. “I believe that is one of the indications for a Ring – patients who have had a previous gastric band. I would also recommend a banded bypass in primary bypasses cases in superobese patients, as the procedure offers a much more durable restriction effect. When the bypass naturally fatigues - because all tissues soften and stretch with time – the added restriction of the MiniMizer Ring ‘protects’ the bypass and reduces the feeling that the restrictive effect has faded.”

He said that he particularly likes the MiniMizer Ring compared to a band as the Ring is easy to apply and calibrate, adding that he has had no complications using the MiniMizer Ring with regards to slippage or erosions, however using an inflatable band for a banded bypass he has had some complications.

“I think the adjustability aspect of bands means than you can over adjust the band and that is when patients will start to struggle this can lead to slippage, migration or dilatation of the pouch above the band which goes against the very reason you placed the band in the first place. The MiniMizer is easy to apply and is placed and fixed so it is ‘snug’ next to the pouch - but not tight - leaving enough space to allow the food to pass through. That is the beauty of the procedure – it is very simple and it seems to works!”

Feedback from patients who have received a Ring after revision surgery reveals that they are happy, because they have a restriction that they can work with. Patients without the Ring are not as happy as they notice the restriction waning as the procedure starts to fatigue.

Managing expectations

Mr Somers explained that another important aspect to surgery is managing patient’s expectations but also difficult because as a surgeon one does not want to put them off the procedure by mentioning weight regain otherwise they will think, ‘Well what’s the point?’

He said that ‘managing expectation’ is a discussion all surgeons should have with their patients, but it should be handled in an honest way and one should approach the conversation from the view that weight regain is a ‘probability’ rather than a ‘possibility’ in the longer term. He said that in discussions with patients, surgeons should be explicit that they are offering patients a tool that can provide a remission from their obesity, rather than a cure.

“I use the analogy of patients being given a new musical instrument. They will need to learn about it and be trained to use it if they are going to get any kind of music,” he concluded. “Furthermore, as the years go by they may need to renew their instrument, or even upgrade. The principle is the same for bariatric surgery.”



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Living with bariatric surgery

In April 2017, Dr Denise Ratcliffe, a Consultant Clinical Psychologist at Phoenix Health, UK and previously at Chelsea & Westminster Hospital, London, UK released her new self-help book: ‘Living with Bariatric Surgery - Managing your mind and your weight’, to help those who are considering bariatric surgery develop the psychological tools to make the necessary changes and adjustments for surgery to be successful. Bariatric News talked to Dr Ratcliffe about the aims of her book, the importance of understanding eating patterns and how managing post-surgical expectations can help people cope with the life changing aspects of bariatric surgery.

“Unfortunately, most people do not have regular or ongoing access to a psychologist when they are going through a bariatric surgery programme, so the aim of the book is to try and address that gap. I have worked in this area for over ten years and the book is really a culmination of all my knowledge and experience in the field,” Dr Ratcliffe began. “The target audience are patients who are in the process of having surgery as well as being a resource for those who have undergone surgery to help them adapt to the physical, psychological and relationship adjustments that occur.  It will also be useful for health professionals who are new to the area and who want to find out more about the psychological aspects of bariatric surgery.”

 

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Denise Ratcliffe

Although the benefits of bariatric surgery are significant, the psychological challenges it can present for patients have been overlooked. Consisting of 12 chapters in over 200+ pages, the book helps patients develop a realistic view of bariatric surgery and the changes required so they can adapt to life after surgery.

“There are no exact numbers on how many patients have access to a psychologist, but for most patients they will have a pre-operative assessment and perhaps some limited post-operative consultation. This lack of post-operative psychological input is very important as it is post-operatively where most of the psychological issues tend to arise.”

"We ask patients to look at what they want from surgery – more often than not weight loss is a proxy for something else – it is more important to them that they feel healthy, be more active with their children, be able to move more freely. Weight is just a number at the end of the day – whereas playing with their children is the real reward.”

According to Dr Ratcliffe, it is important that patients make the necessary psychological changes before and after surgery so that they are better prepared to negotiate the adjustments and achieve their goals, as well as helps normalise some of the issues that they might experience.

Bariatric myths

She explained that there are several myths surrounding bariatric surgery - one of the most common is that surgery will prevent patients from eating and they will never be able to put weight on again. A second myth is that after losing weight, patients will finally be happy and that all their problems will disappear.

“There is also a perception that bariatric surgery is somehow the ‘easy option’ – so some patients feel guilty or ashamed because they feel they are taking the easy route by having surgery – when actually they are choosing the most evidence-based treatment available.”

Many bariatric patients present with a range of psychological conditions ranging from binge-eating and emotional eating patterns, to depression and weight-related anxiety. Psychological difficulties that have occurred as a consequence of weight stigma are particularly prevalent.  These psychological difficulties are often longstanding, with some going back to childhood experiences of abuse and/or neglect. These issues can impact on the type of coping mechanisms that people develop.

“By the time the psychologist gets to meet them, people are often very focused on getting the operation. Quite often they have tunnel vision – they think about the surgery and losing weight and its hard to see beyond that,” she added. “They often cannot imagine what the consequences may be in terms of body image, changing their relationship with food, possible impact on their relationships with friends and family etc. It really is a journey of self-discovery – and there are lots of issues that can arise from surgery. On balance, most people get a real benefit from surgery, but patients need to understand that it is inevitable that there are going to be challenges and set-backs along the way.”

Dr Ratcliffe said it is often difficult for patients to imagine the issues and challenges that may arise after surgery, as they have often had to fight very hard to access the surgery or they have been very focused on losing weight because that is the problem they are trying to address. Therefore, it is essential patients are made aware of what the consequences of surgery might be and that they research possible consequences, as well as speak to other patients who have had surgery.

“For most patients, when they visit a psychologist it is the first time they have had an opportunity to think about the psychological aspects of their eating behaviour. Usually, they have done every diet under the sun and they have really good knowledge about what is in food, what they should and should not eat. However, it is their psychological relationship with food – whether it is emotional eating patterns or binge eating etc – that they often need to address. Many patients use food as a mechanism to cope, so their relationship with food needs to be addressed.”

Moreover, she stressed that it is important that patients think about actively managing mood issues, such as depression and anxiety, either before or alongside surgery. These are not necessarily factors which should prevent people from having surgery, she added, but it is vital that patients are aware so they are able to anticipate, recognise and manage themselves after surgery. By identifying these issues and how they are linking to eating, healthcare professionals can then help patients develop strategies and coping mechanisms, so patients can manage their issues in a different way rather than defaulting to their usual patterns.

Managing expectations

She explained that surgery is about appreciating both the positive aspects and the challenging aspects, so patients comprehend that surgery and the subsequent weight loss is not going to solve all of their problems and make them appreciate that patients will encounter some unexpected challenges and problems along the way.

“Managing expectations around weight loss is fundamental, many patients think that they will get into BMI <25 range. If they do not achieve that they often think that they have failed. So, it is important to communicate what is realistic and what is likely, it is a balance of positive aspects and challenging aspects. We ask patients to look at what they want from surgery – more often than not weight loss is a proxy for something else – it is more important to them that they feel healthy, be more active with their children, be able to move more freely. Weight is just a number at the end of the day – whereas playing with their children is the real reward.”

Dr Ratcliffe explained that many patients do not ‘update’ their body image after surgery, so they look in the mirror and see themselves as the same size that they were before surgery.  It can take the brain some time to catch up and she encourages patients to gather accurate information such as taking photos, paying attention to their new clothes size and noticing things they are physically able to do that were previously not possible.

 “Many patients are also incredibly self-critical about their appearance before surgery and this can continue post-operatively, so we try to get patients to step back from this mindset and focus on the positive aspects such as noticing what the body can do now, the improvements in how the body functions and what patients can do physically after surgery – such as walking up the stairs without becoming breathless - compared to before surgery.”

Excess skin is a really serious problem for many people post-operatively and can be extremely distressing, making people feel even more distressed about their body and their appearance after surgery. It is extremely difficult to access funding for body contouring surgery and so Dr Ratcliffe helps patients to find ways of coping with this (whilst also being realistic about how challenging this is).

“By working on the changes before surgery, patients undergo a much smoother transition. It is like training for a marathon, you would never just get up and run 26 miles, you have to do the training and preparation before-hand, it is really about synching a patients’ behaviour with the post-operative requirements.”

“In some cases, it is those patients who have been the most adherent to their post-surgical programme that present with excess skin. We all have positive, neutral and negative aspects and thoughts about our body and appearance. Many people have got used to being highly self-critical about their image so we ask them to step back and also pay attention to the neutral and positive aspects that they may be overlooking.”

Relationships

Bariatric surgery can have a considerable impact on relationships - in positive and negative ways and this is something patients need to be prepared for. Some of the changes can be unexpected – sometimes there can be elements of jealousy from friends and partners, especially if they struggle with their weight as well. For example, they may encourage them to eat inappropriate foods, so people need to think ahead, be aware this may happen and have a plan of what to do in that situation.

“This is particularly evident in relationships where people are overweight and as one starts to lose weight after surgery, this can cause tension as one partner tends to feel left behind as their partner moves on and more things become possible,” she added. “If there were problems in the relationship before this can become more of an issue post-operatively. It does not tend to impact people who are in happy and functional relationships before surgery.

In addition, she highlighted that often people avoid certain situations because of their weight, so after surgery they encounter new situations and relationships, and often they need support in how to form new relationships, as well as develop their confidence in new social situations, and quite often this will mean learning new skills.

“The process is all about making healthy changes and developing new habits. Bariatric surgery is only a tool and we know that the effects of the surgery will wane over time. Therefore, it is the behavioural aspects that are fundamental to achieving long-term success, patients who implement and adhere to those behavioural changes have much better outcomes, than those patients who are non-adherent,” she concluded. “By working on the changes before surgery, patients undergo a much smoother transition. It is like training for a marathon, you would never just get up and run 26 miles, you have to do the training and preparation before-hand, it is really about synching a patients’ behaviour with the post-operative requirements.”

To order your copy of ‘Living with Bariatric Surgery: Managing your mind and your weight’ by Dr Denise Ratcliffe, please visit the publisher here or purchase from Amazon here



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