Australia has one of the highest rates of obesity in the world, Bariatric News talks to Dr Michael Talbot (University of New South Wales Senior Lecturer, Bariatric Surgeon and OSSANZ Committee Member), about what can be done to curb the rise of obesity and current trends in Australian bariatric treatment.
“My impression is that whenever a Western country performs a demographic survey about obesity they reveal data that puts their country in lead position for the worst figures in obesity until they are leapfrogged by the next western country to do a survey” said Dr Talbot. “What is happening in Australia is mirroring what is happening in every other developed country in the west with obesity prevalence continuing to increase despite our concerns.”
Nevertheless, he adds that there is some evidence to suggest that the rate or prevalence of obesity may slow down or plateau and suggested that Australia may end up with a situation where one-third are obese and problematic, one-third are overweight and one-third are of a normal weight.
He explains that trying to curb the obesity epidemic will be difficult and one which will require a coordinated approach from all public health stakeholders. Indeed, he stated that across all western countries there are no effective co-ordinated public health or primary care measures so far instituted. Prevention is hampered by public health specialists lacking sufficient political clout to introduce health policy, and treatment hampered by lack of dedicated obesity treatment streams in primary and hospital care systems.
“Obesity is multifactorial and too big a problem for any one government department to develop policy around, so rather than having a situation whereby small changes are implemented we end up doing nothing. If you take smoking as an example, it was decades after scientists documented the link between smoking and cancer, before governments took action and even longer until those actions started to produce results. It needed decades of wrangling and incremental steps to change the health of largest swathes of the population and it will be the same for obesity.”
Legislation
According to Dr Talbot, it takes years for changes have a measurable effect when creating public health policy and that public health policy generally requires effective legislation to produce results.
“Previous studies and data have clearly shown that education is mostly ineffective in managing population health,” he explains. “You cannot place responsibility for managing complex risks onto the individual as this is known to fail. We legislate to control seatbelts, smoking, lead in petrol, drink driving and road speeds. The public health specialists know what to do – but it took them a decade or more to convince the politicians and then the public that a change to smoking was needed. Of course, now that these changes have occurred nobody would go back. Once you change public health policy people never want to go back. The difficulty is getting policy to change and start moving forward.”
“Public health policy without legislation is known to be ineffective, so until we have legislation that supports public policy with regards to obesity I predict we will continue to have vulnerable patients exposed to lifestyle factors that promote obesity and obesity related illness,” said Dr Talbot.
Bariatric surgery
Discussing the current status of bariatric surgery in Australia, he said that the vast majority of procedures are performed on a private basis and the in his home State of New South Wales, publically-funded surgery is about one percent or less.
He said that the State governments in Australia seem to be “frantically” trying to avoiding providing a bariatric service as part of the public system, adding that the debate arouses “horrible ethical and equity discussions”.
“We are allowed to treat a whole raft of “lifestyle” disease including cancer, stroke, cardiac disease and diabetes, and while a surgeon could amputate the leg of a diabetic they would not be allowed to offer them surgery to help manage their diabetes condition. We have been in dialogue with our State Government and Health Department for ten years, asking for a state-funded obesity service and we are getting nowhere,” said Dr Talbot. “In our private hospital we are doing some 800 procedures a year, in our public hospital we are lucky if we perform 20.”
Procedures
Over the last six years, Australia has seen the number of bariatric procedures plateau, and as with all healthcare systems the number of procedure appears ‘semi-cyclical’, in that whenever there is a crisis (such as the financial crisis in 2008) the numbers decrease, but overall the numbers have remained unchanged.
There has been a noted shift in the case mix with a decrease in less complex procedures, such as gastric banding, to more complex procedures like sleeve gastrectomy, and according to Dr Talbot the sleeve is now the dominant procedure in Australia accounting for 60-70% of the surgery.
It is difficult to know whether the rise in sleeve gastrectomy procedures is due to the ‘prevailing fashion’ or due to data. Despite the sleeve not having been tested for its long-term durability and safety, it has immediate effectiveness which is obviously one of the drivers of its popularity, he explained.
“With regards to bypass, it is unusual that the rate is so low compared with other Western countries, but I think as surgeons become more confident in what is a highly-complex procedure, it may increase from current levels,” he added. “The bypass does have a longer learning curve compared with a band or sleeve so this may explain why more surgeons do not adopt the procedure.”
Effectiveness
Dr Talbot believes that with regards to the effectiveness of bariatric procedures, it is very much ‘horses for courses’, as each procedure has its own advantages and pitfalls.
“Our own data suggests that they have reasonably equivalent outcomes, but broadly speaking some individuals or group of individuals may do better with one operation than another,” he said. For example, gastric banding is safe and effective but requires a great after care team and the patient must interact with their aftercare team. If a patient tends not to interact with their team or there is no funding for aftercare, then results will be poor. In contrast, sleeve gastrectomy patients do not require as much aftercare to lose weight, which can be seen as an advantage. I don’t believe that we can discharge sleeve patients completely from followup Dr Talbot says. There have been some reported instances of malnutrition following a sleeve procedure and reports about the stability of weight loss long term appear variable. While gastric bypass patients seem to do better ‘pound for pound’ with regards to weight loss and diabetes, there can’t be any debate about their aftercare due to risk of nutritional disturbances and internal hernia formation.
“In a mature bariatric system, all bariatric procedures have their place. As a physician treating a patient you certainly don’t want to limit your ability to offer them treatment. There are some system barriers in all western countries which makes performing some procedures more difficult than others.” We are very lucky in Australia that we are able to offer such a range of treatments too our patients, but the barriers to uninsured patients remain prohibitive. Dr Talbot has been performing bariatric surgery for ten years and carries out banding, sleeve, non-banded and banded bypass procedures. He currently favours the banded bypass in heavier patients primarily due to concerns about maintaining weight loss or preventing weight regain.
“Originally, I was using a band that was made in theatre, but that put limit on the number of bands I was prepared to place because there is always a concern that if you a placing a non-approved medical device in patients you want a good reason for it. The availability of a standardised, easy-to-use band has allowed me to liberalise the banded-bypass to the majority of the bypass patients. I tend to use the Minimizer Ring as it is easy to place and you can calibrate it to the patient at the time of surgery. If you think you need a ring of a certain size and you are wrong, it doesn’t matter as you calibrate it to stomach size at the time of surgery. In ten years of performing banded-bypass I have yet to see a band-related complication so I feel more and more comfortable placing a ring at the time of gastric bypass.”
He adds that one of the reasons was happy with the band was because he felt he had been able to avoid dysphagia by keeping ring size at about 7cm.
“I am worried about creating unmanageable dysphagia in patients. Patients who can’t eat normal food tend to eat carbs and fat and that does not aid weight loss. These days I almost always perform a banded-bypass as a primary procedure, and am very keen also to place a band if revising an LAGB or VBG to gastric bypass. In patients with weight regain after gastric bypass the data tends to suggest that if you are going to using a band to control weight regain following a bypass you are probably better using an adjustable band.”
The future
Dr Talbot believes the future of advances in bariatric surgery will probably not be with new technologies, but rather adjunct treatments and more personalised medicine, which will allow physicians to decide who will do better with a less complex procedure and who will require a more complex procedure.
“I am not overly impressed by many of the new technologies because they are not designed to be permanent – they are temporary treatments to a permanent condition. Some of these technologies could result in a permanent gastric injury, yet the effectiveness of the procedure is only going to be transient.”
He added that pharmaceutical companies could play a key role in future therapies, however he suggested that rather than finding a ‘cure’ for obesity they will end up offering treatments in combination with surgery with specifically designed adjunct therapies. “Bariatric surgery may become more common, but less complex as our understanding of the disease increases. By minimising the impact a treatment has on a patient you are able to increase the number of patients you can treat. We must remember that bariatric surgery as an academic profession is still young compared with many other specialities, it’s a relatively new profession and there is a still lot to be learned.”